EARLY ASSISTANCE REQUEST FORM, CUSP, Washburn University

Washburn University - Celebrating 140 Years

Center for Undergraduate Studies and Programs

(CUSP)

EARLY ASSISTANCE REQUEST FORM

Student success is important to all of us at Washburn University. With your help we can identify students who might benefit from our services.

Instructor: please:

Discuss this issue with the student;
Complete and submit this form;
Print the confirmation screen for your records;

You may want to submit your early assistance request form through campus mail. To do so please select the PDF version of the form.

Instructor and Student data

Student
Name

Instructor
Name

Department
(example:AC)

Course #
(example: 423)

Section
(example: A)

Course
Reference #
( example: 15099)

Course Title

Instructor Comments

Student has never attended class	Student has missed class sessions
Student is inattentive in class	Student has not been prepared for class
Student has not turned in class assignments	Student has turned in below standard assignments
Student seems to have difficulty with:	Student seems to have difficulty with math
language	Student missed the last examination
Comprehension	Student has not performed well on examinations
Writing

Other issues of concern ( please specify):

As the student's instructor, I have discussed the contents of this form with the student, and
he/she is aware that someone from Academic Advising in the CUSP Office will be contacting him/her. (Please ignore this section if contact with student has not been possible.)

Instructor's Telephone Extension

Instructor's Email Address

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