STUDENT OF CONCERN FORM

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RECOGNIZE. RELATE. REFER.

Student of Concern Form

Thank you for your concern regarding this student. After completing this form, you will be redirected to a confirmation page and will receive an email receipt.

For emergencies:

If this is an emergency involving a student or a faculty or staff member, please dial 911 or contact the Emory Police Department at 404.727.6111.

Report Type(s)Required *

EU-Student of Concern Report

Student NameRequired *

Please provide the name(s) of the student(s) involved in this referral.

Additional Student InformationRequired *

Please provide any identifying information you have about the student(s) so that we can follow up on this referral. Please share any information that you have, including (but not limited to) the following:

Emory email address*
Student ID number
Academic Program (PhD, Evening MBA, JM, LLM, etc.)
Phone number (cell and/or emergency contact)
If the student(s) reside on campus, and if so, where?

School EnrolledRequired *

From the options below, please choose the school in which the student is enrolled. Note that this form will be routed based on the selection.

Report of Student Illness

Report of Student Illness Yes Report of Student Illness No

Medical Concern

Please indicate whether the medical concern is COVID or other.

Location of Diagnosis

Please select the diagnosis location.

_____________________________________________________________________________________

Nature Of Concern

Please click "yes" on any or all relevant concerns below. Please note that clicking "yes" on either of categories will generate checklists, wherein you can identify more specific concerns. This referral will be routed to appropriate staff based on your responses.

Student of Concern: Academic Concern

Student of Concern: Academic Concern Yes Student of Concern: Academic Concern No

Academic Resources

This option serves as an alert that you have concerns about a student’s academic performance.

Learning Support Concerns

Choose from the specific concerns outlined below, checking all that apply. In the description box, please provide any additional details.

Academic or test anxiety Low grades / test scores Low motivation / engagement Poor general studying or learning strategies. Poor writing skills Poor time management Poor organizational skills Poor quantitative skills Subject comprehension Academic difficulty Other (describe in the description box below)

Academic Advising Concerns

Choose from the specific concerns outlined below, checking all that apply. In the description box, please provide any additional details.

Change in quality of student's work or academic performance Habitual tardiness Has not logged into Canvas Excessive absences (more than three consecutive classes) Missed test or exam Needs advising support such as choosing a major, assistance with course withdrawal, leave of absence, or other academic actions Not submitting assignments Other (describe in the description box below)

Student of Concern: Social or Behavioral/Emotional

Student of Concern: Social or Behavioral/Emotional Yes Student of Concern: Social or Behavioral/Emotional No

Social Concerns

Please Identify your concerns regarding a student's social well-being from the options below. Choose all that apply, and in the description box below, provide any additional details related to this concern.

Appearance of self-care has declined significantly Immigration Issues Loss of family member or friend Relationship Issues Family Issues Physical Health Issues Other (describe in description box below)

Behavioral or Emotional Concerns

Identify concerns regarding a student's behavioral or emotional well-being from the options below. Choose all that apply, and in the description box below, provide any additional details related to this concern.

Disturbing conduct Disruptive behavior Verbal harassment toward someone else Physical harassment toward someone else Shift in mood that is sudden or significant Concerning use of alcohol and/or other drugs Self-harming behavior (cutting, biting, burning, etc.) Potentially risky behavior (restricted eating, excessive exercise, misuse of medication, etc.) Student self-reported anxiety or depression Thoughts or threats of suicide Has experienced physical abuse Has experienced sexual abuse Student has been missing for more than three days Other (describe in description box below)

Student of Concern: Basic Needs

Student of Concern: Basic Needs Yes Student of Concern: Basic Needs No

Basic Needs

Identify concerns regarding a student's basic needs from the options below. Choose all that apply, and in the description box below, provide any additional details related to this concern.

Emergency Housing Financial Distress Food Insecurity

Student of Concern: Textbook Assistance

Student of Concern: Textbook Assistance Yes Student of Concern: Textbook Assistance No

Textbook Assistance InstructionsRequired *

At this time, SCMIS textbook awards are only granted through the Barnes and Noble University Bookstore. We are unable to process requests from other websites or for online subscriptions unless the online materials can be obtained through purchasing a code from the Barnes & Noble University Bookstore.

In order to continue processing your request, all below information must be provided. Based on your request, a Case Manager may schedule a time to speak with you about your current financial situation and/or additional supportive resources.

First, provide the following information by referring to the textbook look-up page on Emory’s Barnes and Noble shop (https://emory.bncollege.com/shop/emory/page/find-textbooks):

Course number (Eg. MATH 180, Section 2)
Book ISBN number
Book title
Preference of Rental vs Purchase
Preference of New vs Used
Exact cost of each requested text
Total amount requested for all materials

Second, provide a detailed explanation as to why you're not able to cover your textbook costs this semester/your need for assistance:

Your current financial hardship situation
What financial support or income you have

Third, provide your course syllabi in the Attach Documents section.

Upload a syllabus for each class you have requested a textbook(s) for

Please note that SCMIS textbook awards are not meant to cover your total textbook costs, but to assist in lowering your costs. In order to assist as many Emory students as possible, average textbook awards are not greater than $150. All textbook assistance requests must be submitted by 11:59 pm on the date for Partial Withdrawal/Grading Basis Change deadline of each semester.

Please add any relevant details

Submitter Information

Your NameRequired *

Your EmailRequired *

Your PhoneRequired *

Your Relationship to StudentRequired *

Your Relationship to Student: Class Name/Course Number

If applicable, please provide the name/course number of class

Academic Support for Students with Medical Concerns Submission Details

Thank you for submitting this CARE form for students with a medical concern. Someone from the appropriate academic response team will follow up with the student.

Academic Concern Submission Details

Thank you for submitting this Academic Concern on behalf of the student. Someone from the appropriate academic advising or learning support office will follow up with the student within two business days and provide an update to you as soon as they are able.

Please understand that case managers from these offices are not always able to share details about their interactions with the student you referred. They will work with the student and will contact you if needed about accommodations or actions related to your course.

The problem may be one that is not easily resolved. Faculty, please continue to communicate with the student and hold the student responsible for academic work.

Social or Behavioral/Emotional Concern Submission Details

Thank you for submitting a Social, Behavioral, or Emotional Concern Form on behalf of this student. Someone from the case management team will follow up with the student. In order to maintain the privacy of the student, case managers will not contact you directly unless they have questions or a need for follow up.

Students' experiences can be complicated and nuanced and often take time to ensure the student is connected to the right resources. Faculty, please continue to communicate with the student and hold the student responsible for academic work.

Student Basic Needs Concern Form Submission Details

Thank you for submitting a Basic Needs Concern Form on behalf of this student. Someone from the case management team will follow up with the student. In order to maintain the privacy of the student, case managers will not contact you directly unless they have questions or a need for follow up.

Verification & Attachments

Attach Documents/Upload

Please attach any documentation relevant to this referral.

VerificationRequired *

After completing the verification, please hit the submit button below and wait for the page to fully process before closing the browser.

You will be taken to a confirmation page when the referral has been received successfully. Thank you for taking the time to submit this form; a member of our team will follow up shortly.