Bellevue County Truancy Intervention Program

Student last name

First name

Student ID

Birthday
_____/_____/______

Name of school

Grade
_______

Type: public private charter homeschool

home and hosp. inst. online school other
Home phone #:

Address / location

Parent / guardian name (student resides

with):

Address:

Other parent / guardian name:

Address: If address is same as above, put same.

(_____)-_____-______
Home phone #:
(_____)-_____-______

Is student proficient in English? Yes No

List specific academic concerns: _______________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________
Subject / class

Grade

Grade

Report card:
Grade
Subject / class

Grade

Grade

Grade

List specific behavior concerns: ________________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________
List all disciplinary action within the past year. * 1 Student conference 2 Parent conference 3 Removed from classroom 4 Lunch detention
5 Exclusion from school activities 6 After school detention 7 In school suspension 8 Out of school suspension 9 One year suspension
10 Expulsion 11 other
**# of days suspended
Offence
Month
Actions*
# Days**
Offence
Month
Actions*
# Days**

Yes No
Yes No
Yes No
Yes No
Yes No

Does the student currently have an IEP?

Has the student ever had an IEP?
Has the student previously been referred for IEP evaluation?
Did parent / guardian decline to consent to the IEP evaluation?
Is the student currently being evaluated for an IEP?

Disability category:
Please list all the dates the student is referred for an IEP. *Referred by 1 Parent 2 Staff 3 Court 4 Medical / outside professional
** Evaluation 1 Evaluated 2 Not evaluated 3 Currently being evaluated 4 Order pending for evaluation Eligible 1 Yes 2 No 3 Pending
Date
Referred by* Eval.**
Eligible*** Date
Referred by* Eval.**
Eligible***

_____/_____/______
_____/_____/______
_____/_____/______

_____/_____/______
_____/_____/______
_____/_____/______

List all absences this school year:

_____/_____ _____/_____ _____/_____ _____/_____ _____/_____ _____/_____ _____/_____ _____/_____

_____/_____ _____/_____ _____/_____ _____/_____ _____/_____ _____/_____ _____/_____ _____/_____
_____/_____ _____/_____ _____/_____ _____/_____ _____/_____ _____/_____ _____/_____ _____/_____
Please list all juvenile court referral dates. *status 1 currently involved 2 referred / pending 3 previously involved 4 previously not accepted
Date
Reasons for referral
*
Date
Reasons for referral
*

_____/_____/_____
_____/_____/_____
_____/_____/_____

_____/_____/_____
_____/_____/_____
_____/_____/_____

Please list all previous referrals to TIP. * 1 Accepted 2 Not accepted

_____/_____/_____

_____/_____/_____

_____/_____/_____

_____/_____/_____