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Refer a Student

Faculty/Staff Student Referral Form

Please complete the form below with as much information as possible. When you have completed the form, please press the submit button at the bottom. The information you provide will be sent to the Office of Student Academic Success (OSAS) for review. OSAS will look at each situation individually and will work collectively with campus partners to help assist with the issue. You will be contacted about the result of this referral as soon as possible. If you have any questions, please do not hesitate to contact us at: osas@niu.edu or 815.753.5721.

Person Making the Referral

Faculty/Staff Member Name:
Phone:
Department:
College/School:
Email:
Relationship to Student:

Student Information

Student Referring:
ZID:
Year in School:
Email:
Phone:
Major (if known):
College/School:

Referral Information

Reason for Referral (please check all that apply)

Inadequate Class Performance

Social/Emotional Issues

Inappropriate Behavior During Class Meetings

Trouble Transitioning to the University

Other:

Brief description of the reason for this referral:
(please include the course number/relationship to the student)

Does the student know that you are referring them?
Yes
No

Have you spoken with the student about this issue?

If yes, how have you addressed this issue?


Explain if necessary:

What outcome would you like to see from this referral?