Permanent Exclusion Notification

For use from September 2017

This form must be completed on the first day that the pupil is permanently excluded and sent via secure email to , and

A copy of this form must also be sent securely to the Chair of the Governing Body of your school. Please refer to the checklist attached to ensure all procedures have been correctly followed.

1.1 – Referrer’s details
Date of this notification:
Date of the first day of permanent exclusion:
Name and status of person notifying:
School:
Telephone: / Email:
2.1 – Pupil Details
Name: / UPN:
UCI: / ULN:
Gender: / Year Group: / DOB:
Address:
Country of birth: / Nationality: / Telephone:
FSM: ☐ / Pupil Premium: ☐ / Armed Forces Family: ☐ / Child Looked After: ☐
CAF: ☐ / Child In Need: ☐ / Child Protection: ☐ / SEN (please attach): ☐
2.2 - Ethnicity codes
☐White British / ☐Gypsy/Roma / ☐Any other mixed background / ☐Any other Asian background / ☐Chinese
☐White Irish / ☐White and Black Caribbean / ☐Indian / ☐Black Caribbean / ☐Any other ethnic group
☐Traveller of Irish Heritage / ☐White and Black African / ☐Pakistani / ☐Black African / ☐Refused
☐Any other white background / ☐White and Asian / ☐Bangladeshi / ☐Any other Black background / ☐Information not yet obtained
2.3 – Parent/Carer Details
Parent name (1): / Parent name (2):
Person with parental responsibility:
Family details (child’s numerical position in family):
Please stipulate to whom the telephone numbers belong
Home telephone: / Work telephone:
Mobile telephone: / Emergency number:
Language spoken at home: / Interpreter required: ☐
2.4 – Services working with the pupil
Intervention/Agency / Contact name / Telephone, Email
CAMHS / ☐ /
Education Welfare Service / ☐ /
Youth Offending and Target Prevention Service / ☐ /
Fusion / ☐ /
Educational Psychologist / ☐ /
Families Together / ☐ /
Early Intervention / ☐ /
Social Worker / ☐ /
CAF Team / ☐ /
Mentor / ☐ /
Any other:
3.1 - Reasons for exclusion (required for data purposes)
1 / Physical assault against pupil
Includes fighting, violent behaviour, wounding, obstruction and jostling / ☐ /
2 / Physical assault against adult
Includes violent behaviour, wounding, obstruction and jostling / ☐ /
3 / Verbal abuse/threatening behaviour against pupil
Includes threatened violence, aggressive behaviour, swearing, homophobic abuse and harassment, verbal intimidation, carrying an offensive weapon / ☐ /
4 / Verbal abuse/threatening behaviour against adult
Includes threatened violence, aggressive behaviour, swearing, homophobic abuse and harassment, verbal intimidation, carrying an offensive weapon / ☐ /
5 / Bullying
Includes verbal, physical, homophobic bullying, racist bullying / ☐ /
6 / Racist abuse
Includes racist taunting and harassment, derogatory racist comments, swearing that can be attributed to racist characteristics, racist bullying, racist graffiti / ☐ /
7 / Sexual misconduct
Includes sexual abuse, sexual assault, sexual harassment, lewd behaviour, sexual bullying, sexual graffiti / ☐ /
8 / Drug and alcohol related
Includes possession of illegal drugs, inappropriate use of prescribed drugs, drug dealing, smoking, alcohol abuse, substance abuse / ☐ /
9 / Damage
Includes vandalism, arson, graffiti / ☐ /
10 / Theft
Includes stealing school property, stealing personal property (pupil or adult), stealing from local shops on a school outing, selling and dealing in stolen property / ☐ /
11 / Persistent disruptive behaviour
Includes challenging behaviour, disobedience, persistent violation of school rules / ☐ /
12 / Other
Includes incidents which are not covered by the categories above but this category should be used sparingly / ☐ /
3.2 - Exclusion details
Is this permanent exclusion due to repeated disruptive behaviour culminating in a single serious incident?
Nature of the single serious incident:
If this exclusion was for a single serious incident, were other pupils involved?
If other pupils were involved, were any also excluded?
Has this matter been reported to the police?
4.1 – Reason for permanent exclusion
Please give details of the reasons for this permanent exclusion, details of background information, recent behaviour over the last term as well as any other relevant information.
4.2 – Behaviour over last term
Please attach behaviour log and incident reports if available. Please mark X in appropriate box.
Towards Staff / Towards Pupils
Never / Rarely / Sometimes / Frequently / Never / Rarely / Sometimes / Frequently
Verbal abuse
Physical abuse
Disruptive in lessons
Sexual behaviour
Racist behaviour
4.3 – Strategies and Resources
Please explain the strategies or resources the school has used to address the problems to date and how successful these have been.
5.1 – Attendance
% attendance: / No. Unauthorised absences:
Please attach the attendance certificate: ☐
5.2 – Fixed Term Exclusions
Date / Reason / No. of ½ school days lost
6.1 – Academic details
Please attach the pupil’s most recent school report. If not available, please provide the pupil’s latest levels. / ☐ /
7.1 – Risk assessment
Please tick the box if a risk assessment has been previously carried out. Please attach. / ☐ /
8.1 - Declaration
Please confirm that you have carried out the following actions and then sign.
1 / I have written to the child’s parent(s)/carer(s) and have ensured the following information was included in the letter. (for further support, please contact Emma Benaine or Sarah Zheng for a copy of the standard letters) / ☐ /
2 / I have made arrangements to set and mark work for the child for the first 5 days of this permanent exclusion. / ☐ /
3 / I have informed the parents that they have the right to state their case to the Governing Body Discipline Committee and that a special meeting for this purpose would take place within 15 school days. / ☐ /
4 / I have also written that if the decision to permanently exclude the pupil is upheld at the meeting, they may appeal to an Independent Review Panel who may decide that the Governing Body needs to reconsider the permanent exclusion. / ☐ /
5 / I have given the parent(s)/carer(s) the name and address of the Clerk to the Discipline Committee whom any enquiry about the special meeting should be addressed. / ☐ /
6 / I have informed the parent(s)/carer(s) that for the first 5 school days of an exclusion (or until the start date of any alternative provision where this is earlier), parent(s)/carer(s) are legally required to ensure that their child is not present in a public place during school hours without reasonable justification, and that they may be given a fixed penalty notice or prosecuted if they fail to do so. / ☐ /
7 / I have also sent a copy of the letter to the Chair of Governors, together with a copy of this form. / ☐ /
8 / I have sent a copy of this form and supporting documents with a copy of the exclusion letter to the Behaviour and Inclusion Team and the Education Welfare Service.


/ ☐ /
9 / I have ensured that all documentation in relation to this permanent exclusion has been sent securely via email. / ☐ /
Headteacher’s signature: / Date:

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