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Student Name:
KUID:
Email:
Campus:
Lawrence
Edwards
Pittsburg
Salina
Jayhawk Global Online
Level:
BSW
MSW
Date and time of meeting:
Participants in attendance:
Purpose of the meeting was to address concerns with (check all which apply):
Academic Performance
Ethical Behavior
Professional Conduct
Technical Standards
Other Classroom Issues
Other Practicum Issues
Briefly describe the concern:
Brief summary of the meeting:
Committee findings and decision:
(Note: If more information is needed to make a final decision, indicate that below and include the date when a decision will be determined)
Committee needs more information in order to make a final decision:
Yes
No
Student may respond to the SRC review by sending a brief email, which will be included in the student file, to the appropriate Program Director within five (5) business days of the scheduled SRC.
BSW Students -
jmcarlson@ku.edu
MSW Students -
njkepple@ku.edu
Student Acknowledgement:
My signature below indicates I acknowledge the concerns the Committee discussed at the meeting and understand I will receive an electronic version of this report.
By selecting this box, I am indicating I am signing this document electronically.
Student Signature and Date:
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