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PCCUA CARES Referral
Once you complete this form, you will be sharing your academic concern with the appropriate PCCUA staff member who is trained to respond accordingly to meet your academic needs. PCCUA will work diligently to ensure your academic success.
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* Indicates required question
Email
*
Your email
Reporter's Name:
Your answer
Reporter's Email Address:
Your answer
Department, if Faculty/Staff:
Your answer
Campus Location:
DeWitt
Helena - West Helena
Stuttgart
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Student's Name:
Your answer
Student's Email Address:
Your answer
Student's ID Number:
Your answer
Please identify any ACADEMIC PERFORMANCE concerns. Check all that apply.
Academic difficulties due to a disability
Academic difficulty due to lack of understanding content
Difficulty understanding instructional style
Experiencing test anxiety
Grades do not match with student effort
Poor class attendance
Poorly performing in one or more classes
Unsure about career (discipline) choice
Unable to balance work, class, and personal life
External factors interfering with academics
Issues with technology accessibility.
Issues understanding how to use online technology.
Issues understanding educational software (BlackBoard, Microsoft Word, etc.)
Grades jeopardizing your financial aid/scholarship
Other:
Have you reached out to student to offer assistance (Faculty/Staff)?
Yes
No
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Have you reached out to anyone to receive academic assistance and support (Student/Parent)
Yes
No
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Please provide information regarding this referral.
Your answer
Referral Source
Faculty/Staff
Student-self Reported
Parent
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Is the student aware of referral (Faculty/Staff/Parent)?
Yes
No
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Time-frame of concern:
First six-weeks in semester
Mid-semester
Last six-weeks in semester
What is the best method of communicating with the student?
Email
Phone
In-Person
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Send me a copy of my responses.
Submit
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