Report of Student to Retention Committee

Faculty and staff should fill out this form when there is a concern about a particular student. Please fill out all pertinent information so that the Retention Committee can identify the most effective way to support the student in question. All other questions or concerns not addressed in this form should be directed to the Retention committee at . If you would like to discuss this please call Jaime Millburn at 617-745-3875.

Student’s Name

Your Name

Phone Number

Your Email Address

Relationship to the Student (Advisor, instructor, etc.)

Concern or Issue? (Describe situation in clear, simple terms.)

Please describe the process that led to your concern. (Did you meet with the student to discuss? Have you verified the concerns with other sources? Do other faculty/staff members share your concern?) 

How long have you had this concern for the student?

In order to determine an appropriate intervention and/or level of support for this student please select all of the at-risk behaviors listed below that apply to this student. 
Do you feel that this student would benefit from any of the following support mechanisms? Please check all that apply. 


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