Professional Documents
Culture Documents
JHB E1 Intervention Plan EngInteractive PDF 081313
JHB E1 Intervention Plan EngInteractive PDF 081313
JHB E1 Intervention Plan EngInteractive PDF 081313
Grade:
Pupil ID#:
Date of Birth:
Age:
School:
Address:
City:
Zip:
Fathers Name:
Mothers Name:
English
Spanish
Other:
English
Spanish
Other:
Phone Numbers (include student [if available], parent [cell, work, home], other relatives as
necessary, emergency):
Email address:
Sibling name:
School:
Sibling name:
School:
Sibling name:
School:
Sibling name:
School:
Sibling name:
School:
Sibling name:
School:
ID#:
DOB:
ID#:
DOB:
ID#:
DOB:
ID#:
DOB:
ID#:
DOB:
ID#:
DOB:
Revised 08.07.13
Student Attendance History (Days absent, past problems, previous schools, etc.)
New Mexico law requires schools to take measures to assist the student and family in resolving
an attendance problem. Documentation of these interventions is necessary and should include
dates and comments. The following school personnel were utilized in the intervention process:
Designated Intervention Team Leaders:
Attendance and Student Services:
Parent/Guardian (1):
Parent/Guardian (2):
Teacher(s):
Social Worker:
Counselor:
School Administration:
Other:
Revised 08.07.13
Transportation Issue
Too far to go
No money for transportation
Safety Issue
Health Issue
Surrounding neighborhood
Pregnancy
not safe
Lacking medical
school
Academic/School Issue
Problems with teacher or
Gangs
Medical problems
School problem
Substance abuse
Home Issue
care/immunizations
Disability
Mental illness
School refusal
School discipline
Physical/sexual abuse in
Other (specify)
the home
Social Issue
Gender intimidation
Homeless
Gang activity
Neglect
Financial issues
Runaway
Bullying
Family dynamics
Personal relationships
Student Characteristics
Low achievement
Parenthood
Low attendance
Drug/alcohol problem
Credit deficiencies
Discipline referral
Health-related issues
Other:
Specify the details of the attendance problem(s) checked above and describe any applicable
problems not listed above:
2. Collaborative recommendations of the student, parent/guardian and school personnel to
solve the attendance problem:
3. Referred to social service agency (name):
Student counseling
Parent training
Parent counseling
Alternative placement
Student evaluation
Other:
Medical evaluation
Revised 08.07.13
Revised 08.07.13
9. Signatures:
_______________________________________________
_______________________________________________
________________________________________________
_______________________________________________
Student signature
Parent/guardian signature
Date:
Date:
_______________________________________________
_______________________________________________
Date:
Date:
Yes
No
Successful?
Yes
No
Yes
No
Date:
Person/Title Who Initiated Contact:
Phone call
Letter
Certified Letter
In-Person
Other:
Additional Information:
Successful?
Date:
Person/Title Who Initiated Contact:
Phone call
Letter
Certified Letter
In-Person
Other:
Additional Information:
Revised 08.07.13
Successful?
Yes
No
Yes
No
Yes
No
Yes
No
Date:
Person/Title Who Initiated Contact:
Phone call
Letter
Certified Letter
In-Person
Other:
Additional Information:
Successful?
Date:
Person/Title Who Initiated Contact:
Phone call
Letter
Certified Letter
In-Person
Other:
Additional Information:
Successful?
Date:
Person/Title Who Initiated Contact:
Phone call
Letter
Certified Letter
In-Person
Other:
Additional Information:
Successful?
Date:
Person/Title Who Initiated Contact:
Phone call
Letter
Certified Letter
In-Person
Other:
Additional Information:
Revised 08.07.13