Adopted: June 2004
Revised: June 2015
Download 503.3.5P - Staff Notification of Violent Behavior by Students
Date:
To:
From: ____________________________ (name of administrator)
This notice is sent to inform you that the following student has been identified as a student with a history of violent behavior according to school district guidelines. The notice is sent to assist you in helping this student to be successful and ensure 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.
Name of student ___________________________________________________________
Incident(s) of violence ______________________________________________________
____________________________________________________________________________
____________________________________________________________________________
If relevant, and 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 frustrations 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:
q IEP q Functional Behavioral Assessment q Reports from Staff
q §504 Plan q Information from parent or guardian
Additional information may be available to you based on your legitimate educational interest.
c: Cumulative file