Primary Managed Move Referral

Primary Managed Move Referral

Please appropriate box complete and send to the email below:

Newton’s Walk School, Cedar Street, Derby, DE22 1HL

Please Complete this Form as Comprehensively as Possible

Managed Move
School to School / Managed Move
Alternative Provision to School
Young Person’s Details
Student Legal Name in Full / Date of Birth / Year Group / Gender / M/F
Ethnic Group / First Language / UPN
Religion / UCI
Current School / Previous School / ULN
Date of Referral / Is the student considered to be disabled? If yes, please provide details / Yes/No
Parent/Carer Details
Parent/Carer Name in Full / Relation to Student
Address / Telephone
Mobile
Email Address
Other Agencies Involved
Name of Agencies / Contact Name / Phone Numbers
LAC / Y
N / Voluntary / Child protection
SEC 47 / Y
N / Child in Need SEC 17 / Y
N / Private Foster / Y
N / YOS / Y
N
Statutory
If LAC or CP which local authority holds the order:
Pupil Premium
Entitled to free school meals. / Y-N / Pupil Premium (+). / Y-N
Code of Practice
EHCP/Statement / Y - N / Undergoing Assessment / Y - N / SEN Support / Y – N
SEN Details
Specific SEN / ADHD / Asperger’s / ASD / SEMHD / HI / MLD
MSI / PD / PMLD / SLD / SpLD / Other
Are there any access arrangements in place i.e., reader, scribe, extra time, prompter, rest breaks, enlarged paper’s etc.
Describe briefly the student’s Special Educational Needs (Attach supplementary information as appendix A – last two IEPs/MEPs, EP reports, copy of interim review if statemented)
Summarise any health and safety concerns that have been raised. (Attach any supplementary information as appendix G).
Does the student have any medical needs / health concerns / physical needs / prescribed medication: (attach any supplementary information as appendix F)
Has a referral to the single point of access been made / Yes/No
Details:
Safeguarding/Risk Assessment
Has a pre-EHA or EHA been completed for this student? / YES NO
Does this student have a history of violence towards others?
If yes, to whom?
Please provide brief details. / YES NO
Who:
Details:
Does this student pose a significant threat of harm to others? / YES NO
Any other significant event we need to be aware of that may impact on student behaviour.
Current Academic Information*
Is the student currently on the school roll and attending mainstream lessons? / YES/NO
Is the student accessing alternative provision’s e.g. inclusion unit/part time timetable? / YES/NO
Fixed Term Exclusion Data*
FTE Date / FTE Duration / Reasons for FTE / Post Exclusion support given

*Where FTX links to a serious incident then please include a Risk Assessment – Attach as an Appendix 4

Interventions Implemented
Details of intervention Programmes:
Programme/Strategy / Impact / Date/Duration / Outcome
KS1 Assessment Data
End of Key Stage 1 Assessment Data:
Level
SAT
English / Speaking and listening / Reading / Writing
Maths / Using and applying / Number / Shape, Space and Measure
Science / Scientific Enquiry / Life Process and living things / Materials and their properties / Physical Processes
KS2 Assessment Data
Current Assessment Data:
Level
SAT
English / Speaking and listening / Reading / Writing
Maths / Using and applying / Number / Shape, Space and Measure
Science / Scientific Enquiry / Life Process and living things / Materials and their properties / Physical Processes
Current MEP / Yes/No / Current Behaviour Plan / Yes/No / Boxall Profile / Yes/No
Has child been seen by the Educational Psychologist? / Yes/No
What are the Student’s strengths / interest, including activities outside school?
Are Parents Aware of the Referral? What are their Views?
Is the Pupil Aware of the Referral? What are his/her Views?
School to give a brief statement of why you feel this Managed Move could be successful for this student?
Behaviour
Describe briefly the student’s behaviour and involvement of other services or agencies. (Attach supplementary information as appendix B - including disciplinary record / details of incidents, fixed and permanent exclusions, serious incident reports and information to contribute to risk assessment).
Outline information on how well they have accessed learning in the classroom and small groups.
What is the child’s timetable? (Full or part time).
What is the child’s attitude to work, with staff and with peers?
Comment on any specific behaviour issues.
Outline successful strategies for working with the child. Please indicate suggestions for future support to ensure success for this student.
Outline information on reasons for exclusions, fixed term and seclusions.
Attendance
Provide details of current attendance, including details of past two academic years. Summarise any factors that affect attendance. (Please attach attendance print out / Appendix C).
Mental Health
If there have been concerns about the student’s mental health, describe briefly the reasons. Please indicate whether or not a referral has been made to a mental health professional. (If information is available – provide a brief summary below and attach any supplementary information as appendix D).
Social / Home Circumstances
If there have been concerns or information about the student’s social circumstances please describe these briefly below. In particular, comment on any information provided by Social Services, EWS etc. Are there any child protection issues? (Attach any supplementary information, including parent contracts / orders as appendix E).
Any family circumstances we should be aware of.
Health and Safety
Summarise any health and safety concerns that have been raised. (Attach any supplementary information as appendix G).
Any other information
Is there any other information you feel would be useful?

Readiness Integration Assessment

Allocate a score of between 1 and 4 to each of the statements as follows: Please highlight the number appropriate in Yellow
1= rarely fulfils this criteria
2= sometimes fulfils this criterion
3= frequently fulfils this criterion
4= almost always fulfils this criterion
Can accept discipline without argument or sulking / 1 / 2 / 3 / 4
Can arrive in classroom and settle down quietly and appropriately / 1 / 2 / 3 / 4
Does not leave the room without permission / 1 / 2 / 3 / 4
Can accept changes to plans or disappointments with an even temper / 1 / 2 / 3 / 4
Shows some self-discipline when others try to encourage deviation / 1 / 2 / 3 / 4
Is aware of normal sound levels and can be reminded of them and respond appropriately / 1 / 2 / 3 / 4
Does not seek confrontation during unrestricted times e.g. break / 1 / 2 / 3 / 4
Behaves in socially acceptable manner in public e.g. outings / 1 / 2 / 3 / 4
Can maintain appropriate levels of behaviour when the classroom routine is disrupted / 1 / 2 / 3 / 4
Will abide by accepted rules of an organised game / 1 / 2 / 3 / 4
Goes to and stays in designated areas when requested e.g. playground, hall, etc. / 1 / 2 / 3 / 4
Controls emotions appropriately when faced with difficulties e.g. does not fight, strike out immediately, run away and hide or become excessively withdrawn / 1 / 2 / 3 / 4
Behaves appropriately in all areas of the school building / 1 / 2 / 3 / 4
Can cope with large numbers of people / 1 / 2 / 3 / 4
Can accept that teacher time needs to be shared / 1 / 2 / 3 / 4
Can ask a question and wait for the answer / 1 / 2 / 3 / 4
Has appropriate communication skills e.g. asking questions and listening / 1 / 2 / 3 / 4
Can work alongside others in a group situation without disruption / 1 / 2 / 3 / 4
Interacts and plays in positive ways with peers / 1 / 2 / 3 / 4
Apologises without reminder / 1 / 2 / 3 / 4
Asks permission to use objects belonging to another person / 1 / 2 / 3 / 4
Shows empathy for and comforts playmates in distress / 1 / 2 / 3 / 4
Chooses own friends and maintains reciprocal friendships / 1 / 2 / 3 / 4
Makes and accepts normal physical contact with others / 1 / 2 / 3 / 4
Accommodates other children who ask to join in an activity / 1 / 2 / 3 / 4
Is self-reliant in managing own hygiene and basic needs / 1 / 2 / 3 / 4
Shows genuine interest in the news and activities of another child / 1 / 2 / 3 / 4
Contributes actively to play with two or more children / 1 / 2 / 3 / 4
Shows variation in the roles undertaken during co-operative play e.g. is not always in the role of dominant character, etc. / 1 / 2 / 3 / 4
Engages in appropriate conversation with another child, exchanging information and using appropriate dialogue / 1 / 2 / 3 / 4
Addresses adults and children appropriately by name and with eye contact / 1 / 2 / 3 / 4
Shares legitimately required equipment with another pupil / 1 / 2 / 3 / 4
Can take turns in question and answer sessions / 1 / 2 / 3 / 4
Willing to ask for help / 1 / 2 / 3 / 4
Can accept responsibility for actions without denial / 1 / 2 / 3 / 4
Can acknowledge own problems and is willing to discuss them / 1 / 2 / 3 / 4
Can risk failure / 1 / 2 / 3 / 4
States feelings about self, e.g. happy angry, sad, etc. / 1 / 2 / 3 / 4
Maintains appropriate eye contact / 1 / 2 / 3 / 4
Contributes to class discussions / 1 / 2 / 3 / 4
Participates in group work, making constructive suggestions and adapting ideas / 1 / 2 / 3 / 4
Responds appropriately to stories, identifying the characters e.g. funny, kind, scary, bad, etc. / 1 / 2 / 3 / 4
Participates in large class activities e.g. dance, role plays, performances, etc / 1 / 2 / 3 / 4
Accepts public praise and congratulation appropriately e.g. when good work is shown to peers, etc. / 1 / 2 / 3 / 4
Shows pride in achievements and presentation of work / 1 / 2 / 3 / 4
Has self-esteem for self / 1 / 2 / 3 / 4
Can work alone without constant attention for brief periods / 1 / 2 / 3 / 4
Can attempt to listen to explanations and instructions and attempt to act on them / 1 / 2 / 3 / 4
Understands the structure of the day / 1 / 2 / 3 / 4
Understands the role of the teacher and other adults in the room / 1 / 2 / 3 / 4
Understands the structure of discipline – what happens if he/she does not complete work, does not conform to playground rules etc. / 1 / 2 / 3 / 4
Understands that there are different places for lessons other than the classroom e.g. library, hall, etc. and behaves appropriately / 1 / 2 / 3 / 4
Can constructively use unstructured time in the classroom / 1 / 2 / 3 / 4
Can organise him/herself if help is not immediately available / 1 / 2 / 3 / 4
Responds appropriately to personal request from teacher / 1 / 2 / 3 / 4
Will work alongside another pupil without attempting any distractions / 1 / 2 / 3 / 4
Can organise the materials needed for a task and clear them away appropriately / 1 / 2 / 3 / 4
Shows appropriate levels of curiosity when changes to the room routines are observed / 1 / 2 / 3 / 4
Reading and numeracy up to level that can be coped with in a mainstream classroom given reasonable support / 1 / 2 / 3 / 4
Shows a willingness to improve own literacy and numeracy / 1 / 2 / 3 / 4
Can read sufficiently well to understand basic instructions needed for completion of tasks / 1 / 2 / 3 / 4
Has developed some self-help strategies (at own level) e.g. using reference materials as word banks / 1 / 2 / 3 / 4
Does not get up and wander around the classroom without a purpose / 1 / 2 / 3 / 4
Needs a mainstream curriculum / 1 / 2 / 3 / 4
Does not get impatient if help is not immediately forthcoming / 1 / 2 / 3 / 4
Is willing to try complete a task independently / 1 / 2 / 3 / 4
Pays attentions to class discussion and instructions / 1 / 2 / 3 / 4
Is prepared to work in lessons / 1 / 2 / 3 / 4
Uses appropriate language and gestures / 1 / 2 / 3 / 4
Wants to be reintegrated / 1 / 2 / 3 / 4
Has parental support / 1 / 2 / 3 / 4
Is courteous, and shows positive attitude towards staff / 1 / 2 / 3 / 4
Can show an interest in lessons / 1 / 2 / 3 / 4
Treats school property with care / 1 / 2 / 3 / 4
Listens with interest to class explanations / 1 / 2 / 3 / 4
Can accept disappointments e.g. when not chosen to participate in an activity / 1 / 2 / 3 / 4
Will sit appropriately without causing a disturbance in both class and general school areas on request / 1 / 2 / 3 / 4
Shows a sense of humour / 1 / 2 / 3 / 4

Further information

The following information will be used to assist in making decisions regarding the most appropriate next steps for this student.

1. Within the school setting

Copes well difficulty coping (please tick)
1 / 2 / 3 / 4 / 5
Whole class settings
Small group settings
One to one basis
On corridors / general movement around building
Lunch / break times
Before and after school

1. Other indicators of risk

Please indicate whether any of the following apply to the student (please tick)

Never / Occasionally / Frequently
Gives in easily to pressure from others
Has poor control of temper
Challenges authority
Has caused damage to property
Verbally abuses peers
Verbally abuses staff
Displays aggressive behaviour
Has caused deliberate injury to peers
Has caused deliberate injury to staff
Displays sexually inappropriate behaviour
Attempts to manipulate / control others
Is at risk of self-harm
Drugs / alcohol have an impact on behaviour
Has brought in or used an offensive weapon
Has shown racist behaviour

Name of person completing the form: Date:

Role in school:

Check List – Please Tick 

Please include the following documents where applicable:

Attendance Record
Timetable
Behaviour Log
SEN: EHCP/Statement or information submitted for statutory assessment
IEP/MEP/Individual Plan
EP/Steps Assessment
TA (Leader Support) Identified in any Lessons
PEP/LAC Review
EHA or Pre EHA
Risk Assessment
*Parental Consent form for MM-APS- (Must be signed by parent/carer)
Interim Review
Disciplinary Record, exclusions, seclusions
Medical Reports/Prescribed Medication
Social Worker Reports
Parent Contracts/Orders
Any other useful information

We will treat all information provided in confidence and in accordance with the Data Protection Act 1998. We will use the information for the purpose of identifying appropriate support for you and your son/daughter and may share information with our partner organisations for the same purpose. Our partner organisations include the Community Safety Partnership, Central Derby Primary Care Trust, Derbyshire Mental Health Trust, Greater Derby Primary Care Trust, Connexions Derbyshire, Derbyshire Police, Derby Hospitals NHS Foundation Trust.

In Year Fair Access Agreement

For Primary Managed Moves

Parental Agreement/Consent

Student Name______

Name and Roll of School Representative Present ______

I can confirm that the Managed Moves/Hard to Place process was discussed and explained to my child and myself by the above named member of staff.

I understand that at the Panel meeting my child could be allocated to any school within Derby City.

I am in agreement for the process to go ahead.

Signed ______(Parent/Carer) Date ……………….

Signed ______(Parent/Carer) Date ………………..

Primary Form – Jan 16 1