Early Referral Form for Instructors and Advisors

Student Name

Student ID Number

Faculty/Staff Information:

Faculty/Staff Name

Faculty/Staff E-mail

Is this concern related to a specific course? 

If yes, please enter the course.

Student Concerns:

Excessive Absences


Need Reading/Writing skills

Failed Exam

Missed Assignments


The U of R collects information under authority of The University of Regina Act in accordance with the Local Authority Freedom of Information & Protection of Privacy Act and the Personal Information Protection & Electronic Documents Act for purposes of enrolment, academic status, and administration of programs/services. By responding to this form, you consent to the use your personal information to communicate with you regarding Student Success Centre initiatives.