Policy #529 Form

Appendix I



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 or statements by school staff

____ Information provided by the parent or guardian

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