FORM: ACD01.023 ACADEMIC INTERVENTION INTERVIEW FORM

ACADEMIC INTERVENTION INTERVIEW FORM
This form is to be used by Academic Department for the determination of an intervention strategy. Copies should be kept by the student and Academic Department. Once completed, please forward to the PEO.

Intervention Strategy: Intervention Strategy is an action plan adapted in an attempt to reduce the causes of academic failure. It has been developed to offer you with additional assistance to promoting future success in your studies.
STUDENT DETAILS:
Name *

First Name Family Name
Student ID *
Contact Number *
Address *
Email Address *
example@example.com
Course Enrolled *
COURSE PROGRESS DETAILS: (Please tick the appropriate option) *

1st Intervention 1st Warning 2nd Intervention
1st Intervention applies for student who is at risk of failure for the first time or the 1st subject/unit of the term.

1st Warning applies for student who is at risk of consecutive failure in the same term after 1st Intervention.

2nd Intervention applies for student who is at risk of failure in following terms after 1st Warning

Intention to report applies for student who is at risk of failure for 2 consecutive terms and has received 1st Warning. Please use an Appeal form in response to any "Intention to report" letter.
Reason and any supporting documentation why this intervention strategy should be provided: *
Please attach your files here:

Cancel of
INTERVENTION STRATEGY DETAILS: (Please tick one or more options.)
Prescribed Program

Attending tutorials, Reduction in course load, Re-assessment Other
Referral to Student Support

Attending counseling Receiving a assistance with personal issues which are influencing progress Other
STUDENT DECLARATION:

I acknowledge the intervention strategy as outlined above.
Student Signature *

Clear
Date *

Day Month Year
Date
OFFICE USE ONLY
Approval Decided By
Signature

Clear
Date

Day Month Year
Date
FORM: ACD01.023 Academic Intervention Interview Form
LAST UPDATED: Jan 2019, Version No.2
Should be Empty:

ACADEMIC INTERVENTION INTERVIEW FORM

STUDENT DETAILS:

INTERVENTION STRATEGY DETAILS: (Please tick one or more options.)

STUDENT DECLARATION:

OFFICE USE ONLY