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Real Time Alert (RTA) Form

The RTA Form is to be used at anytime during the academic year, or, in "real time" that the situation has occurred or is occuring. Use of this form will initiate an immediate response/contact by Michael Verhagen, Senior DUS Programs Coordinator, or a designee to work with the student in addressing emerging situations. Please be as detailed as possible when completing this form. You may use this form to alert me to any concerns you may have (attendance, change in attitude, grades, etc...). This will enable me to predict needed resources and referrals. You will be provided a summary of action taken.

Instructor or staff name
Course or location
Student's name
Email address of person filling out this form:
Please provide a detailed narrative on what concerns you have about this student:
Please list any attempts that you have made in addressing these concerns:
Please list any suggestions that you may have in addressing these concerns:

  • Please check all that apply to this student:

  • For class issues, please select the most likely outcome at this point in the semester: