Applicant Information
Last Name
First Name
Middle Name
UCC Field of Study/Major
Current Enrolled Credit Hours
UCC Earned Credits
UCC Attempted Credits
UCC Cumulative GPA
Transfer Field of Study
Transfer School
Professional/Career Goal
Other Colleges Attended
Transferred Credits
High School Attended
Describe Your Educational Journey (School/Work Experience)
Did student apply to FAFSA for current school year?
Did student apply for FAFSA for next school year?
What do you know about your major/career goal?
What is the highest level of education student's parent(s) received?
Describe educational support/encouragement received from family or others:
Describe student's strengths:
How important is it for the student to attend every class?
Is the student willing to meet with us at least once per term?
LASSI / Participant Need for Academic Support Services
Info Processing
Main Ideas
Test Strategies
Managing Time
Using Resources
Academic Indicator
Currently enrolled, or needs to be enrolled, in college developmental educational classes
Two or more D's, F's, or W's on transcript in the last three terms of attendance
Currently on UCC Academic Probation or Suspension (if yes, verify document on file)
Currently on UCC Financial Aid Probation or Suspension (if yes, verify document on file)
Current UCC or Transfer GPA below 2.5
Special help needed to maintain or increase for scholarship/financial aid/transfer
Undefined educational goal
Undefined career goal
ESL (English as second language)
Out of educational system for 5 years or more
High Risk Predictive Indicator
GED or Adult High School Diploma
Working 30 or more hours per week while in school
Commutes over 50 miles roundtrip to UCC
Single parent or issues regarding childcare
Independent student (FAFSA) under 25
No family support stated on application/interview
Only income State/Federal/VA Assistance
Referred by faculty, staff, or community member
Transportation issues
Housing issues
Physical health issues
Emotional health issues
Are there any other life barriers that you have experienced that you would like us to know about?
Connected with Accessibility Services
Interviewer Signature
Please select a signature verification type.