START Program - Confidential

*Student's Name
 Course

*Faculty Member Name
 *Faculty Member Username
(Do NOT include "@westminster.edu" in your username.)

In the space below, explain reason(s) for concern about the student. For example: Student displays a sudden dramatic change in behavior in class (i.e., frequently appears intoxicated, consistently misses class, appears depressed, etc.). A copy will remain on file in the Office of Student Affairs and also will be sent to the Campus Representative(s) selected to assist the student.

Not attending class
Missed assignments
Poor performance in class
Other

Comments

When the SUBMIT button is pressed, this form will be sent electronically and confidentially to the Vice President for Student Affairs.




* - Required