Special Educational Needs and Inclusion Services
NOTIFICATION OF PERMANENT EXCLUSION
To be fully completed and returned on the day of permanent exclusion to:
(This will enable the LA to provide the Alternative Provision from Day 6 from the permanent exclusion)
Name of School / Dfe NoContact Person/ Position / Contact Tel Number/ Email:
Please specify with x if your school is:-
Academy / Maintained School / Special School / PRU / Other (please specify)
Pupil Details
Surname
First Name / Middle Name:
Address
Postcode
Telephone No
UPN / Gender (please specify with x) / Male / Female
Date of Birth / --/--/---- / NCY Group / Key Stage
Parent / Guardian Carer Details
Parent / Guardian / Carer Details – (Please specify with x) / Parent / Guardian (e.g Grandparents) / Carer
Title / Mr/ Mrs / Miss /Ms
Surname
First name
Full Postal Address (if different from above)
Are there any issues with home visiting this family that you are aware of. / Yes No
Please provide any relevant details.
Please specify details of other person with Parent responsibility (with address if not same as above). Are there any known risks to the family preventing us from confirming this permanent exclusion to the other person with parental responsibility Yes No
Parent / Guardian / Carer Details – (Please specify with x) / Parent / Guardian (e.g Grandparents) / Carer
Title / Mr/ Mrs / Miss /Ms
Surname
First name
Full Postal Address (if different from above)
Telephone No
Comments
Is the Pupil a LAC / Yes / No
Have there been any CAF / EHA meetings called / Yes / No
Is the Pupil on a Child Protection Plan
Please specify Lead Contact person and tel no. / Yes / No / Contact:
Telephone:
Does the pupil have an IEP / PSP. If yes please attach last available copy of IEP/PSP / Yes
**School to include PSP/IEP Plan / No / Contact:
Telephone:
Has the Pupil been the subject to a Managed Move.
If yes please provide the following Information:- / Yes / No
Name of School:
Last Review Date:
Date of Breakdown:
Reason for Breakdown:
Does the Pupil have an SEN – Please specify SEN type / Yes / No / Does the Pupil have an EHCP Plan? Yes/No
Please attach a copy of the most recent if yes
SPLD/MLD/SLD/PMLD/ASD/HI/VI/MSI/PD/
ADHD/ODD/OTHER (Please specify)
Does the pupil currently receive in class support? / Yes / No / Details: Frequency/subject/hours:
If the Child has an EHCP Plan – please provide Keyworker Name and Contact Number / Key Worker Name
Contact Number
Is the pupil in receipt of Free School Meals / Yes / No
Does the pupil attract Pupil Premium / Yes / No
Ethnicity (Please tick one box)
- British
- Indian
- Irish
- Pakistani
- Traveller - Irish Heritage
- Bangladeshi
- Gypsy/Roma
- Any Other Asian Background
- Any Other White Background
- Chinese
- White/Black Caribbean
- Any Other Ethnic Group
- White/Black African
- Refused
- White/Asian
- Any Other Mixed Background
- Traveller
- Black Caribbean
- Asylum Seeker
- Black African
- Any Other Black Background
Exclusion Reason (Please tick one box)
PP
PP / Physical assault against a pupil / SM / Sexual misconduct
PA / Physical assault against an adult / DA / Drug and alcohol related
VP / Verbal abuse/threatening behaviour against a pupil / DM / Damage
VA / Verbal abuse/threatening behaviour against an adult / TH / Theft
BU / Bullying / DB / Persistent Disruptive Behaviour
RA / Racist Abuse / OT / Other
Have the Police been informed / involved in connection with this Permanent Exclusion / Yes / No
Permanent Exclusion Details
First Day of Permanent Exclusion / --/--/----
6th Day of Permanent Exclusion
Are there any planned INSET days during the 6 day period?
Please do not include INSET days in your calculation. / --/--/----
Yes/No
Agencies Involved
Agency / Yes / No / Contact Person / Outcome/ Details
Child In Need / Child Protection
TAC
EHA/LST
BRFC
T3
YOT
GP
OTHER – Please specify
Physical/Medical Conditions. Including illness/allergies
Including Pregnancy / Medication and administration details:
Mental Health Conditions:
Agency Involvement: / Medication and administration details:
Social Welfare Issues: / Specific Needs:
**School to provide Pastoral Support Plan or Behaviour Plan if the pupil has one with this form **
Strategies in place for pupil
Yes / No / Yes / No
Support from Tutor / Placement at LSU
Learning mentor / Reduced Timetable
Peer Mentor / Managed Move
School Report / Alternative Education
Other (Please specify)
Attendance Data
Please specify over the last/current Academic Year pupil attendance / …………………………%
Is the learner punctual? / Yes/No
EWW involvement (attendance) / Yes/No
** Pupil Academic Profile – Please include the most recent school report for ALL year groups and include with this form. **
Education History (Additional to referring school)
School/Provider:
Pastoral Contact:
Contact Number:
Dates:
Reason for Leaving:
School/Provider:
Pastoral Contact:
Contact Number:
Dates:
Reason for Leaving:
KS2 SAT’s / Predicted Grades / Actual Results / KS4 GCSE’s / Predicted Grades
English / English
Maths / Maths
Science / Science
KS4 Additional Information –
Subject / Exam Board / Course work completed to date (Please forward) / Predicated Grades
Additional Information
Name of Headteacher / Date --/--/----
** Please include where requested the additional information to be provided with this form. See Checklist below **
Schools Checklist – Please include the following information with this form.School to include PSP/IEP Plan /
Yes No
School to Include details of the Statement or the EHCP Plan /
Yes No
School to provide Pastoral Support Plan or Behaviour Plan if the pupil has one /
Yes No
Pupil Academic Profile – Please include the most recent school report for ALL year groups /
Yes No
ATTITUDE TO LEARNING
Where 8 is ‘Excellent’ and 0 is ‘Completely Disengaged and/or Extremely Disruptive’, please score the learners AVERAGE
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8
POSITIVE CONTRIBUTION TO SCHOOL COMMUNITY
Please state, as an approximate percentage, the leaners’ quantity of positive engagement during a week: / %
BEHAVIOUR CONCERNS (0= No concern, 1= Some concern, 2= Serious Concern)
Refusal to Comply / Disruption (learning centred) / Disruption (outside lesson time)
Work Avoidance / Absconding / Uniform
Verbal Abuse (Peers / Staff) / Physical Abuse (Peers / Staff) / Dangerous/Risky Behaviour
Other(s):
BEHAVIOUR TRIGGERS (i.e. Times of day/week, subject, staff, peers, social, family, emotional, learning etc.)
Please detail any identified antecedents to regular behavioural difficulties:
BEHAVIOUR INTERVENTIONS (Action taken specifically to reduce behaviour concerns)
Date / Behaviour / Intervention / Outcome
EXCLUSIONS (PAST THREE TERMS)
Date / Specific Reason(s) / FTE (Days) / Perm
To be completed by PRU/SSS if required
LEARNER PROFILE (For Completion by/with learner)Areas of school I enjoy/are successful in are:
The areas of school I need support to find success in are:
My interest/hobbies outside school are:
These are the skills/qualities/strengths I have:
In the future I would like to… (i.e. after Year 11)
In school I have had problems with…
I think ______may be good for me because…
Learner Signature: / Date:
PARENTAL CONTRIBUTION
What involvement have you had in school based work to resolve educational issues?
My hope for my child’s time at further education is…
Specifically, my son/daughter needs…
The following are strategies to try or strategies to avoid with my child:
Avoid / Try
INITIAL RISK ASSESSMENT
Potential Hazard/Behaviour / Opinion/
Known
(O/K) / Deliberate/
Accidental/
Involuntary
D/A/I / Seriousness
Of Outcome
(A)
1/2/3/4 / Probability
Of Hazard
(B)
1/2/3/4 / Severity of Risk
Score
(A)x(B) / Risk Rating
Harm to Self
Harm to Peers
Harm to Staff
Damage to property
Harm from Disruption
Criminal Offence
Harm from Absconding
Prevention of Learning
Travel Related Issue
RISK RATING
1-2 / Universal Risk Management, specific plan not required
3-4 / Consider control measures, plan carefully
6-8 / Risk Manage, specific control measures required
12-16 / Very high risk, extensive Risk Management
Notification of permanent exclusion-attainment record-PRU referral form - 2017