Online CARE Report

Responsibility for self and others is explicitly named among Middlebury’s Community Standards. We care for one another, and sharing information about someone whose wellbeing you are concerned about is an act of this care. Many thanks for answering the questions below.

NOTE: Please use the direct, clean link to this report form and use that link only. Bookmarking a previously used URL will cause errors in submitting these reports.

URL: https://middlebury-advocate.symplicity.com/care_report

* indicates a required field

CARE Network

Vermont campus students, faculty, and staff may use Care Form submissions to:

*Share concerns about the wellbeing of a student

*Request Student Access and Support Grants

*Complete important tasks related to leaves of absence, course alerts, 5th course adds, and final exam change requests.

MIIS students, faculty and staff may use Care Form submissions to share concerns about the wellbeing of a student.

MIIS Faculty may also use the Care Form to submit Course Alerts.

Submissions are reviewed during regular business hours each day the College and/or Institute is open.

If this is an emergency, please contact Public Safety in Vermont at (802) 443-5911 or in Monterey at (831) 647-4153.

911 functions on both campuses as well.

If you have questions about this form please contact the CARE Management Office, at middCARES@middlebury.edu.

Affiliation with Middlebury / MIISRequired *

Please indicate if you are a student, faculty or staff member, and whether you are in Vermont or at MIIS.

NameRequired *

Please provide your full name.

Reporter's EmailRequired *

Please provide your email address so that we can contact you if we have follow up questions about this report.

What type of faculty report would you like to make?Required *

What type of student report would you like to submit?Required *

Student(s) InvolvedRequired *

Please provide the name and ID (if known) of the student(s) involved. Vermont students only: If entering Student Access and Support Grants, Leave of Absence-related requests, Admin Committee petitions, 5th course adds, etc., enter your own name and ID#.

May we share with the student that you submitted the concern?Required *

May we share with the student that you submitted the concern? Yes May we share with the student that you submitted the concern? No

Class Dean Affiliation

Class Dean

Date/Time of Incident

What was the approximate time that the situation occurred?

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Where did this situation or Incident occur?

DescriptionRequired *

Please provide as much information as possible about the situation or request, including the names of any other involved individuals aside from you and the student of concern.

FACULTY REPORTS

Complete this section if you are faculty.

Graduation Term

Students cannot graduate with any INC grades on their transcripts. INC must be resolved before final grades are due for graduating seniors.

Term and Year of CourseRequired *

Outstanding work and completion planRequired *

Please enter the work that you are agreeing to accept and the specific dates, if applicable, that the work needs to be turned in by. This completion plan is an important component of a student’s ability to successfully resolve an incomplete as well as a required piece of record keeping for the Registrar.

Student Due DateRequired *

This is the date by which the student needs to submit all outstanding work, which will ordinarily be before the deadline for adding classes in the following Fall or Spring semester. The deadline may be no later than the deadline to drop classes in the following semester. Incompletes in winter term courses will follow the same procedures: the deadline for the submission of all remaining work may be no later than the deadline to drop classes in the Spring semester.

Submit grades byRequired *

This is the date by which the faculty member is agreeing to submit a grade for the student. If no grade is submitted by this date, the grade will be recorded as the Provisional Letter Grade entered above.

Provisional Letter Grade Required *

This is the grade the student would receive if one was issued at this time.

Study Abroad Advisor

Name of academic advisor

Email address of academic advisor

Please Select Reason(s) for This Course AlertRequired *

Does Not Participate in Discussions Hands in Work Late Low Grade on Assignments Missing Assignments Other Poor Attendance

Professor's comments to studentRequired *

Your narrative here will be sent directly to the student. Remember, students do best when feedback is focused on concrete behaviors (e.g., “you missed 2 out of the last 4 quiz sections” vs. “you don’t seem very engaged”) and is coupled with viable steps for getting back on track (e.g., “let’s set up an appointment to meet and discuss how you can make-up the work you missed. I would like to see you turn in a version of the discussion section activity no later than a week from today”). These narratives are also great opportunities to direct students toward course specific resources (e.g., “I find that students often benefit from setting up weekly appointments with peer tutors in the writing center. I encourage you to set up an appointment and bring the instructions for our first writing assignment with you. I have enjoyed hearing the perspective you share in class and look forward to reading your continued analysis in the paper that is due on October 12th.”

If applicable please provide information on any supports or resources you have referred the student to.

STUDENT ENTRIES

Complete this section if you are:

*A Vermont or MIIS student wishing to share concerns about a peer

*A Vermont student requesting a 5th course add or final exam date change or submitting an Admin Committee Petition.

Course InfoRequired *

Please provide the Course Registration Number, course and Section (if applicable) , and course title. For example "CRN 727456-FYSE 1572A- Rites of Passage"

Course NameRequired *

Name of course for 5th course adds or final exam changes.

Faculty Involved

For course alerts or course related concerns, please include the Professor's name

Term and Year of Course for Add or Exam ChangeRequired *

Exams ScheduledRequired *

Please list all scheduled final exams along with the date, time, course info and instructor of record associated with each exam (do not list papers or projects):

Have you discussed your request with any of your professors? Required *

Have you discussed your request with any of your professors? Yes Have you discussed your request with any of your professors? No

Please share the details of this discussion:Required *

What is the reason for requesting this final exam change?Required *

In the fields below please provide details for the course/final exam you are hoping to change.

If you are requesting to change your final exam due to an emergency or compelling and unusual circumstances please provide an overview of your circumstances here. Any related documentation of your circumstances should be uploaded in the document box at the bottom of this form. Final exam changes cannot be made to accommodate travel or due to athletic events (please speak with your coach for guidance). Information on rescheduling final exams can be found in the Middlebury Handbook.

Email address of course instructorRequired *

Enter the name of the instructor for the course you wish to add or for which you would like to change your final exam date.

Have you attached a copy of the approval from the course instructor? Required *

upload document below

Have you attached a copy of the approval from the course instructor? Yes Have you attached a copy of the approval from the course instructor? No

Have you attached the approval from your academic advisor?Required *

upload document below

Have you attached the approval from your academic advisor? Yes Have you attached the approval from your academic advisor? No

STUDENT ACCESS AND SUPPORT GRANTS

2/21/25 UPDATE: Due to a dramatic increase in requests for travel assistance, effective immediately, we are only able to support supplemental travel once an academic year (while funding lasts). We are therefore currently prioritizing otherwise eligible first-time travel assistance applicants. If you received travel assistance in fall 2024, you will next be eligible to apply in the 25/26 academic year.

Which best describes the reason for your funding request?Required *

Please select the choice which best described your reason for requesting a grant.

If you are looking for financial support for textbooks, please check in with Student Financial Services (SFS).

If you checked "other" above, please share the reason for your request.Required *

Itemized BudgetRequired *

Please provide an itemized budget of projected expenses below.

Amount RequestedRequired *

Amount you can personally contributeRequired *

Be realistic about what you can or cannot contribute without causing undue hardship. Even very modest personal contributions help us support more students, but none are necessary.

Have you discussed your request with a faculty or staff member? If so, who?Required *

Although not required, some students find it helpful to discuss their request with a trusted dean or other staff member, or with a faculty member.

Have you applied for/or received any other funds for this request? If yes, please list source and amount.Required *

Our hope is to support as many students as possible. This information helps us consider requests as fairly and equitably as we can. Examples of other funding sources include the Center for Careers and Internships, the Center for Community Engagement, The Innovation Hub, the Center for Teaching, Learning and Research, and departmental grants.

Date funds are needed.Required *

Date funds are needed. Please note that these requests take at least 10-15 business days to go through; it is quickest to apply early and with receipts for reimbursement.

Please check all that apply to you.Required *

This information helps us to direct you to additional supports which might be available, as well to understand the needs of various constituencies on campus.

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Have you received a previous Student Access and Support Grant?Required *

I understand that these grants were formerly known as Seizing Opportunities and Dean's Emergency funds. I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render refusal of this application.

Have you received a previous Student Access and Support Grant? Yes Have you received a previous Student Access and Support Grant? No

If you checked "Yes" above, please provide the amount.

Initial to acknowledge that you will provide all receipts upon completion of your experience.Required *

The quickest way to get this grant processed is a reimbursement. Please upload your receipts using the upload box at the bottom of this application. If you don’t have a receipt yet, please email it to ehammond@middlebury.edu after your purchase.

Questions and comments are welcomed and appreciated. What would you like us to know about your experience with this program?

Would you like to speak directly with someone about your application?Required *

If you answered yes, you will hear from us within one week or feel free to stop by the AFC (Carr Hall 103) during open hours to chat with Elaine.

Would you like to speak directly with someone about your application? Yes Would you like to speak directly with someone about your application? No

LEAVES OF ABSENCE

Complete this section if you are a student taking a leave, returning from a leave, or continuing an existing leave.

Leave of Absence Type

What is the reason for your leave of absence request?Required *

Are there conditions for return in your original leave letter?Required *

If your letter requires you to submit documentation prior to your return this indicates you are on a leave with conditions. Please upload documents at the end of this form. If you do not have documentation at this time please email it to sldeansoffice@middlebury.edu as soon as possible. Medical Return Forms (MRF) should be emailed separately to counseling@middlebury.edu. Your return is contingent upon written approval from your dean.

Are there conditions for return in your original leave letter? Yes Are there conditions for return in your original leave letter? No

Term student began, or will begin, LOA

Current term, Spring 2020, etc.

Anticipated term for return

This is the academic term that the student plans to return following their leave of absence. Normally, readmission is for fall or spring semester only. Students will be readmitted for a winter term or summer student only with special permission from the Vice President for Student Affairs or designee.

Have you consulted with your Class Dean about the academic feasibility of a Temporary Medical Leave?Required *

Absences due to Temporary Medical Leaves are excused but work missed must be made up. If you are not current with all work, taking time away may present significant academic challenges. We strongly advise that if you have not already done so, you speak with your class dean and your faculty immediately to make a plan for catching up.

Have you consulted with your Class Dean about the academic feasibility of a Temporary Medical Leave? Yes Have you consulted with your Class Dean about the academic feasibility of a Temporary Medical Leave? No

Have you completed the Temporary Medical Leave form in your Pyramed Health Portal?Required *

This form is required for all Temporary Medical Leaves. If you have not already done so, please complete it immediately.

Have you completed the Temporary Medical Leave form in your Pyramed Health Portal? Yes Have you completed the Temporary Medical Leave form in your Pyramed Health Portal? No

When do you anticipate your Temporary Medical Leave will begin? Please enter a specific date.Required *

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Where do you plan to spend your Temporary Medical Leave? Please specify on or off campus.

Temporary Medical leaves ordinarily must be spent off campus. In exceptional circumstances, you may request permission to remain on campus during your leave.

When do you plan to return to campus after your Temporary Leave of Absence?

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When do you plan to resume attending classes? Note that this must be within 10 class days of the start date of your leave.

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Please describe your plan for recovering/returning to daily life at Middlebury after your leave.

This might include campus, community, or home resources and relationships you’ll use, skills you’re planning to develop, or ways that you’ll adapt to your daily life if you anticipate any changes.

Name of parent/guardian

Please add name of parent/guardian(s) you would like notified of your return. If more than one please separate with a semi-colon.

Email address for parent/guardian

If more than one please separate with a semi-colon.

International Student

If checked yes, it is essential that you consult with ISSS before submitting taking your leave to avoid unintended visa complications..

International Student Yes International Student No

Have you submitted your medical return form (MRF) to the Center for Health and Wellness (CHW)?

Instructions and deadlines for submitting your MRF are in your original leave letter.

Have you submitted your medical return form (MRF) to the Center for Health and Wellness (CHW)? Yes Have you submitted your medical return form (MRF) to the Center for Health and Wellness (CHW)? No

On what date did you submit your MRF to the Center for Health and Wellness?Required *

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Would you like to schedule a meeting with a Care Manager?Required *

The leave of absence process can be complicated, and speaking with someone knowledgeable in College support systems can be very helpful. Care Managers are ready to help!

Would you like to schedule a meeting with a Care Manager? Yes Would you like to schedule a meeting with a Care Manager? No

Due date for ensuring your medical provider has submitted your MRF to the Center for Health and Wellness.Required *

Select the date 7 business days after the date you listed under "When do you anticipate your Temporary Medical Leave will begin? Please enter a specific date",

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ADMINISTRATION COMMITTEE PETITION

Administration Committee Petition Details

Please indicate the purpose of your petition below by selecting Yes for as many categories as apply, and submit the required materials by uploading documents prior to submitting this form.

If you have questions, please contact the Administration Committee Coordinator at admincommittee@middlebury.edu.

Professor Grade Change Request

Professors must submit a grade change form to the committee in support of your request. If you have not already done so, ask your faculty member to do so as soon as possible.

Professor Grade Change Request Yes Professor Grade Change Request No

9th Semester Approval

Your petition should indicate the barriers to completing your degree in 8 semesters. It must include:

*a Completed and signed Degree Audit form (see go/registrar.forms).

*A letter of support and/or confirmation from a professional caregiver (counselor, etc.) and your Class Dean as appropriate.

F-1/J-1 visa holders must also email ISSS at (isss@middlebury.edu) to indicate that you're submitting an Administrative Committee request for 9th Semester Approval, along with a copy of the petition.

(Note: It's recommended that you schedule an appointment with an ISSS advisor to discuss the potential implications of the outcome on your visa status/SEVIS record so you're aware.

9th Semester Approval Yes 9th Semester Approval No

Late Course Drop for Administrative Error; Exceptional Personal Circumstances; and Significant Injuries and Non-chronic Illness

If never attended the course: petition, signed drop card, and confirmation from professor that never attended

If exceptional personal circumstances or related to a significant injury or non-chronic injury (non-disability-related): petition, and confirmation letter from professional caregiver (counselor, physician, etc.) and/or Dean

If this will reduce your course load to 2 or fewer classes, see "Reduced Course Load for Exceptional Personal Circumstances" below

Please review the Satisfactory Academic Progress (SAP) policy (go/sapp). If your late drop will compromise your required progress, meet with your advisor and/or Dean to develop a plan to address this

F-1/J-1 visa holders should consult with ISSS before petitioning

Late Course Drop for Administrative Error; Exceptional Personal Circumstances; and Significant Injuries and Non-chronic Illness Yes Late Course Drop for Administrative Error; Exceptional Personal Circumstances; and Significant Injuries and Non-chronic Illness No

Reduced Course Load (<3) for Exceptional Personal Circumstances

All materials noted above under "Late Course Drop," above, as appropriate

F-1/J-1 visa holders must also submit a letter of approval from ISSS

Please review the Satisfactory Academic Progress (SAP) policy (go/sapp). If your reduced course load will compromise your required progress, meet with your advisor and/or Dean to develop a plan to address this

Reduced Course Load (<3) for Exceptional Personal Circumstances Yes Reduced Course Load (<3) for Exceptional Personal Circumstances No

Waiver of "Senior Year in Residence" Requirement

Your petition should include:

*Brief letter explaining your reasons for the request.

*Completed signed Degree Audit form (see go/registrar, Forms)

*Notes of support from academic advisor and Dean

F-1/J-1 visa holders should consult with ISSS before petitioning.

Waiver of "Senior Year in Residence" Requirement Yes Waiver of "Senior Year in Residence" Requirement No

Permission to Retake a Course

Petition

Note of approval from course professor

Permission to Retake a Course Yes Permission to Retake a Course No

Reinstatement

Petition

If the applicant is a senior seeking reinstatement in order to transfer final credits back to Middlebury, the petition should also indicate a request for a waiver of the Senior year in Residence requirement (see above)

Official transcript(s) with credits to transfer

Reinstatement Yes Reinstatement No

Readmission after Academic Failure or Suspension

Refer to your original withdrawal letter for deadline dates.

After academic failure: Petition, official transcript from accredited college/university with grades of B- or better in four liberal arts courses

After suspension: Petition, other accompanying documents as required by terms of suspension (see outcome letter)

Readmission after Academic Failure or Suspension Yes Readmission after Academic Failure or Suspension No

Attach documents/Upload

Petition Type not listed

Please indicate the nature of your petition in the text box below

Late CR/NCR Invocation for Exceptional Personal (non-medical/non-disability-related) Circumstances

Petition

CR/NCR Request Form approved by Registrar's Office (form available at Registrar's Office)

Confirmation letter from professional caregiver (counselor, etc.) and Dean as appropriate

Late CR/NCR Invocation for Exceptional Personal (non-medical/non-disability-related) Circumstances Yes Late CR/NCR Invocation for Exceptional Personal (non-medical/non-disability-related) Circumstances No

DOCUMENT UPLOADS

You may upload 5th course add approvals and documents pertaining to Admin Committee Petitions here.