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Academic Intervention Report

Please submit this form if you are a faculty member with a student of concern (academically) during the semester. Please complete one form per student. Information will be shared with the Academic Intervention Committee, the student’s primary advisor, and/or other USC Union staff in order to conduct outreach. Thank you for sharing your concerns and making a difference in the USC Union community.

This form must NOT be used to report emergencies. If you need to report an honor code violation, please complete the Honor Code Violation form instead. If you need to report self-injurious, concerning, or erratic behavior, please submit a referral to the Care Team. If there is a possibility that a student may harm themselves or others dial 911 immediately.  

*Required fields

Indicate your role and relationship with the student
Indicate the concern(s) regarding this student. Check all that apply. *
Have you addressed these concerns with the student?
Has the student expressed any thoughts of withdrawing from the university?
Is the student aware of this referral?
Time-frame of this concern