Student Referral Form

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Student Referral Form

Please fill out the below information to the best of your ability.

Please be aware that this does not constitute filing an official police report. To file an official police report, please contact the University of Massachusetts Boston Department of Public Safety at 617-287-1212. For incidents occurring off-campus in the City of Boston, please call 617-343-4730.

IF THIS IS AN EMERGENCY, PLEASE CALL 617-287-1212 OR 911!

Please be aware that all reports, including anonymous reports, regarding alleged discrimination, harassment, sexual or gender harassment, domestic or dating violence, stalking or retaliation pursuant to the Equal Opportunity Discrimination and Harassment Policy and/or the Student Code of Conduct need to be submitted under the ODEI Complaint Form.

Background Information

This form is for the use of current students, faculty, or staff from the University of Massachusetts Boston. Please provide detailed information regarding the academic concern you are reporting.

Use this form if you have been unsuccessful in resolving an issue on your own. Once the form is submitted, the student's academic advisor will review the information and take appropriate action.

As the Student Referral Program does not respond to emergencies, the report may not be reviewed and/or immediate action taken on the same day it is submitted.

Student Referral Program

Please fill out the below information to the best of your ability.

IF THIS IS AN EMERGENCY, PLEASE CALL 617-287-1212 OR 911!

Background Information

This form is for the use of current students, faculty, or staff from the University of Massachusetts Boston. Please provide detailed information regarding the academic concern you are reporting.

Use this form if you have been unsuccessful in resolving an issue on your own. Once the form is submitted, the student's academic advisor will review the information and take appropriate action.

As the Student Referral Program does not respond to emergencies, the report may not be reviewed and/or immediate action taken on the same day it is submitted. If you have any questions related to completing this form, please call ACES at 617-287-5500.

Referrer Information

Your full name:

Your position/title:

Your phone number:

Your UMB email address:

Course title & section number:

How urgent is this report?
If this is an emergency, call 911 or 617-287-1212

Student Information

Student's name:

Student's ID number:

Please include all 8 digits, including leading 0s

Referral

Have you attempted to discuss this concern with the student?

YesNo

In addition to this referral, we suggest that you attempt to discuss the issue with the student.

I am most concerned about the following behavior: (Please select one)

Please describe your concern here using specific, concise, and objective language. Indicate the actions you have taken with the student to address the concern.

What recommendations do you have for the advising intervention? (Select all that apply)

Consider the pass/fail optionConsider the course withdrawal optionSchedule a meeting with professor to discuss class progressVisit tutoring & academic supportVisit the Ross Center for Disability ServicesVisit the Counseling Center

Students benefit when they are aware of their class progress early in the semester. What is your assessment of the student's current status in your course?

Supporting Documentation

Attach any photos, email, or other supporting documentation to help the advising intervention. Maximum file size supported: 5MB.

Click the button below to submit this referral to the student's advisor. A copy of your submission will be sent to your email (at the address you provided above).

UMass Boston

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