Louisiana Tech University Student Concern Form

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Please use this form to convey any academic or non-academic concerns about a student at Louisiana Tech, and a member of the Bulldog Achievement Resource Center or Counseling Services will respond accordingly.

Email *

FACULTY/STAFF INFORMATION

Faculty/Staff Name: *

Relation to the Student: *

Instructor, Academic Advisor, etc.

Course (if applicable):

STUDENT INFORMATION:

Student Name *

Campus-Wide ID Number: *

Classification

Freshman

Sophomore

Junior

Senior

Other:

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FACULTY CONCERNS

Please Check All That Apply

ACADEMIC CONCERNS:

Student...

is not attending class regularly

Is routinely late for class and/or routinely leaves class early

is disruptive or rude in class

neglects to finish and/or turn in assigned work.

is routinely not prepared for class

requires study skills assistance.

is having difficulty with career decisions.

is not utilizing the services of the Bulldog Achievement Resource Center (BARC) or other academic support services as prescribed.

Other:

NON-ACADEMIC CONCERNS:

Student...

has a housing/roommate concern.

is having difficulty adapting socially.

could benefit from substance use/abuse education.

is allowing extra-curricular activity to interfere with academic progress.

cannot find extra-curricular activities that meet his/her interests.

has personal problems (family members, home, etc.) appear to be interfering with social and academic development.

has expressed extreme concern with financial issues.

has general mental health concerns (if you are concerned for a student's personal safety, please contact Tech PD at 318-257-4018)

Other:

Any other additional information that would be helpful in assisting this student?

Would you like to remain anonymous to the student?

Yes

Other:

Clear selection

A copy of your responses will be emailed to the address you provided.

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