Retention Alert Form - Murray State University

	Office of Student Affairs
	Registrar's Office

Retention Alert Form

	Contact Us
	Don Robertson Vice President of Student Affairs 116 Ordway Hall Murray State University Murray,Ky 42071
	Phone 270-809-6831
	Fax 270-809-4176
	For items g, h, and i, email student.loans@murraystate.edu

for Faculty Use Only

The purpose of this form is to enable the Office of Student Affairs to assist students who are encountering academic difficulties. When this is received, one of our professional staff will attempt to follow up with the student. If you would prefer to confer privately, contact Mike Young, Assistant Vice-President for Student Affairs, at (270) 809-6831 or Carmen Garland, Special Assistant to VP for Student Affairs at 809-5344.

Please complete the following information. A copy of the completed form will be e-mailed to you for your records.

Student's Name
Last 4 of Student's SSN
Course
Section
Date
Instructor
Instructor's Department
Instructor's Phone Number
Instructor's Full murraystate.edu* Email Address (required)
Select any of the following options that apply:	a: receives failing grades b: frequently misses classes c: frequently fails to turn in assigned work d: seems to lack direction/goals e: seems to have personal problems f: other - please fill in below

	For mandatory periodic reporting: g: has never attended or done any work h: quit attending Date of last academic activity (attended, took exam, or turned in assignment): / (month / day)
	i: Update-- Previously reported as not doing academic activity, but returned since last report. (Please provide information in the comment box below.)
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Murray State University