Report of Student Concerns

1. Name of Student:

2. Student ID Number:

3. Date of Conversation with Student:

4. Connection to Student

Teacher
Academic Advisor
"Unofficial" Advisor
Staff
Residence Assistant
Peer Advisor

4a. Name of Person Filing Report

5. Reason(s) for Student's Concerns:

Campus Facilities
Campus Social Life
Lack of Academic Progress
Professors / Advisors
Macon / Bibb County
Boyfriend/Girlfriend Concerns
Athletics
Academic Programs
Financial Concerns
Psychological Concerns
Medical Concerns
Housing Concerns
Family Concerns
Ethnic/Gender Concerns
Other

6. Has this student indicated that s/he may be leaving Mercer?

Yes
No

6a. If so, when?

Next semester
Next year
In two years

7. Please provide a brief narrative description of the concerns expressed by the student, and indicate to what extent you have offered advice on how the student should address the concerns, or have the concerns addressed.