Academic Intervention Referral Form

  • Please complete and submit the form below to refer a student. By completing this form, you will be sharing your concern with KSU Staff members who are trained in responding to student needs. Thank you for sharing your concerns and making a difference in the KSU community.

  • In the event of an Emergency, do not use this form. Call KSU Police immediately by dialing 6878 or 911.

  • Background Information


    Upon completion and submission, this form or information contained therein may constitute an educational record of any student(s) referenced, and is protected from disclosure except in some limited circumstances. As educational record of a student, that student may have a right to review the form. The University will endeavor to maintain the information contained in the form as private, to the extent required and allowed by law. The information contained in this form may be disclosed to appropriate University staff for evaluation and/or response including, but not limited to the following: KSU police, Student Affair, Academic Affairs, Academic Center for Excellence, Center for Academic Persistence and Success, Student Support Service, Disability Resource Center, and/or Student Health Services. This form is NOT to be used to report emergencies.

    If there is a possibility that a student may harm themselves or others dial 911 immediately.

  • Disclaimer Acknowlegement

  • Student of Concern
  • Additional Information and Questions
  • Supporting Documents