CONFIDENTIAL THIS INFORMATION IS NOT TO BE SHARED

STAFF NOTIFICATION OF VIOLENT BEHAVIOR BY STUDENT

To: Teachers and Supervisors of J.P.__________________________________________

From: Administrative Dean____________________________________________________ Date of Notice: 1/2 /1!______________ Date Notice "#pires:$ %/!&/1'______________ (if no further incidents occur)

This notice is sent to you as required by Minnesota Statute 121A.64 and 121A.75 that the following student has a history of iolent beha ior. The notice is sent to assist you in hel!ing this student to be successful and ensuring the safety of students and staff.
Students Name: J.P. S+%!!,: C%as-a H#.% S+%!!, Students Date !" B#$t%: &'(')* /$ade: 01t%

In+#dent2s3 !" V#!,en+e: (Description/e#p*anation of incident(s) if +no,n and an- miti.atin. factors/ e...0 se*f1defense0 defense of others0 medication issues0 etc.). Jessica ,as frustrated 2- another student ,ho ,as

a*,a-s standin. too c*ose to her *oc+er. She ended up .ettin. into an ar.ument that *ed to pushin. and thro,in. items at another student.

T45es !" s#tuat#!ns that mi.ht provo+e vio*ent 2ehavior 2- this student if +no,n (e...0 initiators for frustration or an.er). Jessica can 2ecome frustrated ver- 3uic+*-0 especia**- if others are in her 4persona*5

space. She can a*so 3uic+*- esca*ate ,ith others ver2a**- if confronted ,ith conf*ict.

St$ate.#es !$ #nte$6ent#!ns that are successfu* ,ith this student0 if +no,n :

Jessica is dia.nosed ,ith "6D and her case mana.er is 6i** Fer.uson. 7f -ou notice that she has hi.h an#iet-0 p*ease refer her to 8r. Fer.uson or a Dean.

The fo**o,in. documents ma- 2e avai*a2*e for -ou to revie, re.ardin. this student: 9______ 7"P _______ '&: P*an _______ Functiona* 6ehaviora* Assessment _______ 7nformation provided 2- parent or .uardian
Pa.e 1 of 2

_______ ;eport/statements 2- schoo* staff

Form '2 1Staff Notification (1/&:)

Additiona* information ma- 2e avai*a2*e to -ou 2ased on -our *e.itimate educationa* interest. " #eha ior !rior to $anuary 1% &otification 'ust occur in that school year and the following school year. #eha ior on or after $anuary 1% &otification 'ust occur in that school year and the following two school years.

Form '2 1Staff Notification (1/&:)

Pa.e 2 of 2

CONFIDENTIAL THIS INFORMATION IS NOT TO BE SHARED

STAFF NOTIFICATION OF VIOLENT BEHAVIOR BY STUDENT

Students Name: Jess#+a P%#,,#5s Date !" N!t#+e: 0'7)'08

Students Date !" B#$t%: &'(')* Date N!t#+e E95#$es:: ('81'0; (if no further incidents occur)

The following staff ha e been notified of the abo e student(s iolent beha ior.
Sta"" mem<e$ name
(p*ease print)

CL

C!

Cu

P!s#t#!n (chec+ appropriate 2o#) De FS =.$ Pa$a P$#n

T+%$

T$an

Ot%

Cheryl Boe Kristal Newman Zach Williams Anne Mette-Bovard Eric Payne Gretchen Ricci Bill a!er "ri Pham #t!dent #!$ervisors %oor Greeters

x x x x x x x x x x x

Bl!e o!se #ec Geo&& Cain

x x

Cl = Clerical Co = Counselor Cu = Custodian De = Dean FS = Food Service Mgr = Manager/Coordinator/Supervisor

Para = Paraprofessional Prin = Principal Tchr = Teacher Tran = Transportation Oth = Other

" #eha ior !rior to $anuary 1% &otification 'ust occur in that school year and the following school year. #eha ior on or after $anuary 1% &otification 'ust occur in that school year and the following two school years.
Form '2 1Staff Notification (1/&:) Pa.e ! of 2