Herberger Institute Student of Concern Form
The Herberger Institute for Design and the Arts students of concern process gives faculty, staff, family members, peers, and other people the ability to make the dean's office aware of specific student concerns for Herberger Institute for Design and the Arts students. Once alerted about a potential student issue, the dean's office will identify the appropriate follow-up based on the nature of the concern. The core team meets twice a month to review issues with ASU partners from across campus as well as academic stakeholders.

Please note, this form is NOT meant to be used for immediate concerns or emergencies (please refer to the previous page for emergency resources). This form is also ONLY for referring current Herberger Institute for Design and Arts students. If you are concerned about a student in another ASU college, please contact ASU Student Rights and Responsibilities at 480-965-6547.

Please fill out the following form to the best of your knowledge.

Student First Name *
Your answer
Student Last Name *
Your answer
Student School *
Student Academic Program *
Your answer
Student ID Number (if known)
Your answer
Definitions - Level of Concern
Minimal Concern - Concerns in which there is minimal or low impact to a student’s life and wellbeing without consequences.

Moderate Concern - Concerns in which there is low to medium impact to a student’s life and wellbeing with uncertain consequences.

Significant Concern - Concerns in which there is medium to high impact to a student’s life and wellbeing with direct consequences.

Serious Concern - Concerns in which there is high and certain impact to a student’s life and wellbeing with severe consequences or harm.

Level of Concern *
Definitions - Areas of Concern
Academic - Student needs to develop further course-based or academic skills. Examples of an concern is the area is lack of class attendance, missed assignments, or need of additional academic support.

Social/Personal - Student needs to develop personal connections with peers, staff, or faculty for a sense of belonging. Examples of a concern in this area is homesickness, isolation, or lack of engagement.

Emotional/Behavioral/Wellbeing - Student shows symptoms of depression, anxiety, or other emotional states that may inhibit their ability to succeed as a student or overall wellbeing. Examples of a concern in this area is a student acting disruptively in a classroom, disengaging from activities, or anxiety about their future.

Health/Illness/Injury - Student experiences issues in areas of health, injury, or illness. Examples of a concern in this area is a sudden injury, lack of balance in school life affecting health, or lack of sleep impacting their ability to be a successful student. .

Financial - Student expresses concern over their ability to cover tuition or basic living costs in the immediate future. Example of a concern in this area is a student divulging that they have a significant account balance that prevents them from registering for class or retaining to the institution.

Area of Concern for Student: *
Does the student live on or off campus? *
Description of Concern
Please describe your concern, including what led to the concern: *
Your answer
Have you discussed the situation with the student? *
Describe what happened during the conversation or why no conversation took place. *
Your answer
Referral Information for Follow-Up
Name of Person Referring Student: *
Your answer
Email of Person Referring Student: *
Your answer
Office Phone of Person Referring Student:
Your answer
Department of Person Referring Student: *
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