529F - Staff Notification of Violent Behavior By Students Form

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POLICY #529F

MODEL NOTICE

STAFF NOTIFICATION OF VIOLENT BEHAVIOR BY STUDENTS

To: (Staff Name)                          ___________________________________________

From: (Administrative Official)  ___________________________________________

Date of Notice:                             ___________________________________________

This notice is sent to inform you that the following student has a history of violent behavior. The notice is sent to assist you in helping this student to be successful and ensuring the safety of students and staff. You can use what you have learned about the student’s history of violent behavior only to the extent allowed by school district policy. The data on this form are private data under state and federal law, and the student’s privacy rights must be protected.

Student’s name:                            ___________________________________________

Incident(s) of violence:                ___________________________________________

___________________________________________________________________________

______________________________________________________________________

______________________________________________________________________

If staff have a legitimate educational interest, provide the following information.

Description/Explanation of incident(s) if known (Specifically include any mitigating factors, e.g. self-defense, defense of others, medication issues):

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

The types of situations that might trigger violent behavior by this student, if known (e.g. triggers for frustration or anger): _______________________________________

______________________________________________________________________

______________________________________________________________________

Strategies or interventions that are successful with this student, if known:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

The following documents may be available for you to review regarding this student:

____ IEP                                                                        ____ §504 Plan

____ Functional Behavioral Assessment                      ____ Reports/statements by school staff

____ Information provided by the parent or guardian

 

Additional information may be available to you based on your legitimate educational interest.