Academic Intervention Reporting Form

In the event of an EMERGENCY, please do not use this form. Call LSUE Police (337-550-1225) or call 911.

LSUE Student Success Center provides staff support for the LSUE C.A.R.E. team, which is an essential asset to the LSUE community.  By completing this form, you will be sharing your concern with LSUE staff members who are trained in responding to student needs and academic struggles.  Thank you for sharing your concerns and making a difference.  If you need to report academic misconduct, use the "Back" button/arrow to select the correct form.

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 an 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. Questions regarding the form and its completion or use should be addressed to ( 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: LSUE Police, Student Conduct, an academic college, Student Health Center, Disability Services, Residence Life, Academic Affairs, and/or the Student Success Center. This form must NOT be used to report emergencies. 
Firstname Lastname
I understand that this form must NOT be used to report emergencies.
Please identify any ACADEMIC PERFORMANCE concerns that you have about this student. Check all that apply:
Please provide as much specific information as possible regarding your referral.
Referral Source:
Have you addressed these concerns with the individual?
Has the student expressed any thoughts of withdrawing from LSUE that you are aware of?
Timeframe of concern: