BEHAVIORAL CONCERNS THAT INTERFERE

WITH LEARNING IN THE CLASSROOM

Your Name :
Your Email Address:
Student's Name:

Student's ID Number:             

GENERAL CHARACTERISTICS :        Please check all that apply.
 
NOTE:
Because of confidentiality, disability issues and/or accommodation concerns should NOT be included on this form. These concerns should be directed to the Disability Services Office at 424-8378.
 
Student has sought help from me.
 
Student has problems attending class.
 
Student dominates classroom discussions in an inappropriate manner.

Student has difficulty staying awake.

Student has difficulty focusing.

 
Student has negative/argumentative attitude in class.
 
The following behaviors may require immediate attention and may warrant contacting the Dean of Students' office at 424-8209.

 

Student exhibits threatening behavior toward self, other students, and/or instructor.
 
Student is disruptive in class.
 
 
Other: Please explain.
 
 

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