Faculty/Staff Student Referral Form
TRIO Student Support Services for Students with Disabilities (SSSD) - Georgia Southern University
SECTION 1: REFERRING FACULTY/STAFF INFORMATION
Name
*
First Name
Last Name
Title
Department/Office
Phone
(999)999-9999
Email
*
example@example.com
SECTION 2: STUDENT INFORMATION
Student Name
First Name
Last Name
Student ID (if known)
Email
example@example.com
Phone
(999)999-9999
Major
SECTION 3: REASON FOR REFERRAL
REASON FOR REFERRAL (CHECK ALL THAT APPLY)
Academic difficulty (low grades, failing, etc.)
Needs tutoring or study skills support
Financial concerns
First-generation college student
Student with a disability
Lack of engagement / attendance concerns
Needs assistance with time management
Needs graduate school or career preparation support
Personal challenges impacting academic success
Other
SECTION 4: ADDITIONAL COMMENTS
Please provide any additional information that may help us support this student.
SECTION 5: PERMISSION TO CONTACT
PERMISSION TO CONTACT
Yes, I have informed the student that I am referring them to TRIO SSSD
No, please contact the student directly without prior notification
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