Early Intervention Request Form

Instructors should complete this form to request assistance in reaching students who have missed orientations, fallen behind in coursework, neglected to submit assignments or exams, or if DL can provide ACC student services referral information to you or your students.

Early Intervention Request Form
Instructor Information:
or Note: After submitting the form, you will be redirected to the Distance Learning homepage.
Instructor Name:	ACC Email Address:
Campus:	Phone #:
Intervention Request:
Course:	Synonym:
Student(s) to be contacted: (Please provide each at-risk student's name & 7-digit ACC Student ID Number.)
Intervention Request: (Please explain how DL can assist you with your at-risk student(s). Provide the text to be distributed and/or background of the request so DL can provide the most appropriate referral for your students.)
Method of contact requested: Email US Mail Phone Call

Instructor Information:

Intervention Request: