Student Name: ___________________________ Student NLU ID: __________________
Cohort/Graduation Class: ___________________ Date of Referral: _______________
Required Documentation
Complete
N/A
Date Verified
Verified By
Referral for Dismissal Review with grounds identified (Section VII)
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Supporting performance data and documentation
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Remediation plan(s) and outcome(s), or basis for immediate referral
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Written notice to student and evidence of delivery
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Student written statement, if submitted
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Interim measures documented, if any
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SEPC meeting record, vote, and recusals
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SEPC written recommendation
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Program Director decision
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Notice of Dismissal or other written decision delivered
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Registrar, Financial Aid, Student Accounts, and Dean notified
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Clinical site(s) notified, if applicable
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University appeal and outcome documented, if applicable
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Record filed in secure student educational record
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STUDENT ACKNOWLEDGMENT I acknowledge that I have been provided access to the NLU Master of Science in Physician Assistant Studies Student Dismissal Policy, that I have had the opportunity to
NLU MSPAS Student Dismissal Policy
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