CONCERN FORM - PDF document

1 CONCERN FORM Purpose: The p urpose
CONCERN FORM Purpose: The p urpose of the Concern F orm p rocess is for f a cul t y to i d entify stud e nts who may need r e mediation or intervention to suc c essfully c omplete the professional requirements for their program of study. Th is form is only to be u s ed af ter t he f a c ul ty member has m e t with t h e st u d en t, d ocu m e n ted t h e c o n c e r n, i nf o r m ed t he a dvisor a nd g iv e n t he st u d e nt an o ppo r t u n i ty to i m prove. If t he pers o n initi a ting the fo r m as su mes the r oles of Progr a m C hair a nd a d visor to the s tudent, a d i fferent Program Chair will be asked to j o in the m e eting. Process Steps: A. Faculty compl e tes a concern form a nd gives it to the Program Chair. B. Action plan may be devised. C. If a warranted a c t ion plan is n ot c ompl e ted to the s a tisf ac t i on of all pa r ties, t h e s t u d ent may be dismissed from his/her program of study. D. If the Co ncern Fo r m is a re s ult of acad e mic di shone s ty, the f a culty m e mber has the addition a l option of submitting a Report of Academic Dishonesty to the appropriate office. In ad d ition to b eing part of the s tud e n t ' s departmental advising fo l der, this rep o rt will be m a de part of the stud e nt’s d i scipl i nary record and sh a ll remain on file in a c cordance with Board of R e gents r e cord retention p olicy. Ty p es of Concerns: Exam p les of behavior warranting a Concern form: • Student who is absent a n d /or late for plac e me n t (see University policy and cour s e syllabus). • Student who does not exhibit profes s ional dress or d e me a nor when i n ter a ct i ng with s t ud e nts, co l labo r ati v e teachers, or faculty as defined by the Sch o ol of E ducat i on a nd cooperat i ng s c h o ol. • Student who does n o t d e mon s trate a n ability to c o ntri b ute e ff e ctively in a g r oup sett i ng. • Student who exhib i ts a l a ck of prof i c i e ncy in written and/or language skills. • Plagiarism or che a ting on any graded a c tivity (Use University policy ) . • Blat a nt d i s h o nesty or bre a c h o f confidentiality. (HIPPA/FE

2 RPA) • Student who is not
RPA) • Student who is not a d equately prepar e d in content or pedagog y . • u de n t who exhib i ts disr u ptive b e hav io r tow a rd fell o w students, faculty or st a ff in all professional settings. No t e: Co n c e rn Forms t h at do not re s ult in an a c t i on plan should be plac e d in the stud e nt’s folder. C oncern F orm Conse q uences: Concern Fo r ms wh ic h r e sult in a d e veloped action plan, may jeopardi z e t h e st ud e nt b eing pl a c ed i n fie l d experiences or clinical e a nd/or not b eing pl a c ed in field experiences or clinical ex p eriences the following se mester. If the student is a l ready pl ac ed in a field experi e nce or clinical ex perience a t the time the Concern Form is filed and the action plan is developed, the student may be removed from the field e xperience or clinic a l exp e rience and may rec e ive an “ F ” gr a de in the fi e ld experi e nce or clinical experience class or fi e l d experie n ce o r clin i al ex p erience c om pon e nt o f t h e class. If the student refuses / fails to comply wit h a ny par t o f the con c e rn process (e.g. meet with faculty member, meet wi t h department head, or si g n forms), the student m a y be r e mov e d fr o m the S c h o ol of E d uc a ti o n a nd / or any fie l d experience o r cl i nic a l e xp erience in w hich he/she i s currently e nrolled. T he stud e nt will not be al l ow e d to enr o ll in any further field ex p eriences or clinical experi e nces or profe s sional class e s u n til the s t ude n t c o mp l ies with al l components of the action plan. The student may appe a l any aspect of the Conce r n Form proce s s to the Dean of the School of Educ a tion. C ON C ERN FO R M St u de n t N am e: I D No. Major: Advisor: Na m e of f aculty me m ber init i at i ng t he Concern Re p ort: Complete the following: 1 St a te the concern: 2 Give evidence for area ( s) of conce r n. Att a ch copies of document a tion. 3 Doc u men t t he s t ude nt’s respo n s e t o t he c o mp le t io n o f t he c on c er n fo r m. 4 S i g n t he f a c u l ty st at e m e

3 nt b e lo w ; h ave t he st ud
nt b e lo w ; h ave t he st ud e nt s i g n t he s t u de n t s t a t e m e n t b e lo w. Faculty statement: I have met with the student and discussed the concern(s). M G A SOE Fa c ulty Signature Date St ud e nt s t a te me nt: I have met with the faculty m e m b er(s) and discussed the concern(s). Student Signature Date 5 M eet with Progr a m Ch a ir a nd s tudent. Com p lete the following: No a c tion plan warranted. ( P rogram Chair reports de c ision of no a c tion taken to faculty member filing the conce r n form). Action plan warranted (see next page) D i s t r i b u t e c o p ies o f t his fo r m a nd the Ac t i o n P l a n ( i f a p pl i c a b le) to the De a n , D ean ’ s A d m i ni s t r a t ive Ass i s t a nt, Program Chair, Field Coo r dinator, F a culty Member, A d vi s or, St u d e nt, a nd the S t ud e nt Ad v is i ng Fo l der Signature of faculty member initiating c o n c ern form: Date : A CT I ON PLAN St u de n t N am e: I D No. Major: Advisor: Fa c u l ty m em ber: D ept: R equired P rogram C h air: Compl e ti o n D ate: Acti o n Plan: I u n derst a nd th a t fai l ure to co m ply with this a c t i on p l an may res u lt in my n o t co mpl e ting my program o f study. St u de n t : D ate : T his ac tion pl a n has be e n complet e d to the s ati s f ac tion of all parti e s. Program Chair’s Signatu r e: Dat e : D i s t r i b u t e c o p ies o f t his fo r m a nd the Ac t i o n P l a n ( i f a p pl i c a b le) to the De a n , D ean ’ s A d m i ni s t r a t ive Ass i s t a nt, Program Chair, Field Coo r dinator, F a culty Member, A d vi s or, St u d e nt, a nd the S t ud e nt Ad v is i ng Fo l der. Revised 9 - 4 -