Student Behavior Reports

Report #	Report Description	Student Name	Grade	School	Description	Updated By	Updated On
85758	Figting Harassment	ALLEN, Andrew Parker	9	Bristol Elem	Evan Pretended to chock another student out of anger	Lindsay Acosta	Today 08:28

Date :

Student Name :

School :

Grade :

HR Teacher :

Student Address :

Phone Number :

SSN number :

Date of Birth :

Age :

Gender :

Race :

Medicaid # :

Parents/Guardian Name :

Phone :

Presenting Issue :

Concerns :

Dates of Actions Before Referral to Social Worker :

Actions Before Referral :

Phone Call

Mailed Letter

Letter sent home with Student

Conference with Parent/Guardian

Unable to contact Parent/Guardian

SS Case #78550

06/24/2020 08:30

Presenting Issue : Pregnancy / Suspected Pregnancy - Child Abuse / Suspected Child
STUDENT	ALLEN, Andrew Parker Grade 9, Rydell High
HR TEACHER	Lindsay Acosta, Teacher
STUDENT ADDRESS	123, Sloan Lane, Athens, AL - 35611.
PHONE NUMBER	123-456-7890
SSN	123456789
DATE OF BIRTH	12/22/2005
AGE	15
GENDER	F
RACE	W
MEDICARE NUMBER
PARENT/GUARDIAN NAME	Will Parker, Sarah Parker
PHONE	123-456-7890
CONCERNS	Other students reported that the student said she was pregnant. Other observations were made to suspect possible abuse.
BY	Lindsay Acosta

Response

06/24/2020 09:06

BY	Lindsay Acosta , Teacher
ACTIONS	Phone Call : 09/20/2019 Mailed Letter : 09/22/2020

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Case #	Student Name	Presenting Issue	Summary	Last Updat Date	Direct Services	Comments
45	Allen, Andrew Parker	In-Class Behavior	Student's in class behavior has suddenly changed.	10/01/2019	Classroom Observation Student Interview Contact Parent/Guardian	Student's parents are frequently flighting and causing problems at home.

Conduct a threat assessment for a student who may pose a threat to themselves, others, or school property

Initiate and track a threat assessment for a threatening incident or concerning behavior.

New Threat Assessment

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Case #	Threat Level	Threat To	Student	Summary	Reported by	Reported	Witnesses	Status
12	High	Harm to Self	JOHNSON, Samantha	Student stated she wanted to "Hurt herself"	MGee, Greta	04/22/2020	Joe Smith Sarah Jones	Assessing

Student Behavior Reports - Current School Year

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Report #	Report Description	Student Name	Grade	School	Description	Updated By	Updated On
78550	Figting Harassment	ALLEN, Andrew Parker	9	Bristol Elem	Evan Pretended to chock another student out of anger	Lindsay Acosta	11/15/2019 08:28
58969	General Misconduct	ALLEN, Andrew Parker	9	Bristol Elem	Arguing	Tammi England
58758	Figting Harassment	ALLEN, Andrew Parker	9	Bristol Elem	Instigating a fight between Lamisha and Kourtney in P.E.	Stefanie Barr	05/17/2019 14:08

Behavior

Attendance

Grades

Behavior Summary

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Session	Discipline Report	Positive Report
2017-2018 Rydell High School	19 (17 ODR)	2

Alerts

Schedule and Activities

Period	Course	Teacher
1	German 1	Acosta, Vera
1	World History : 1500-PresentHGr9	Buck, Joel
2	Algebra 1	Day, willie
2	Prin Biomedical Sciences-PLTW	Justice, Chrysantha
Power Hour	HmroomGr6-12	Melendez, Macie

Contact Details
Mail to Parents

Student

Email	andrew.allen@example.com
Phone (Primary)	256-555-1017
Address	#25, Green Street, USA

Mother : Jennifer Allen

Custodian Emergency Contact Family Member
Email	jennifer.allen@example.com
Phone # (Primary)	256-555-1017
Phone # (Cell)	256-555-8307
Phone # (Work)	256-555-4225 (Ext. 754)
Address	#25, Green Street, USA

Father : Jason Allen

Custodian Emergency Contact Family Member
Email	jason.allen@example.com
Phone # (Primary)	256-555-1017
Phone # (Cell)	256-555-8111
Phone # (Work)	256-555-9644
Address	#25, Green Street, USA

Parents Email :

Email Subject :

Email Description :

Send

SECTION I – CHILDREN ALLEGEDLY ABUSED OR NEGLECTED

Sr. No.	Full Name	Gender	ETHNICITY	DOB
1
2
3
4
5

Street Address
City
State
ZIP
Telephone

SECTION II – OTHER PERSONS LIVING WITH THE CHILDREN

(Include parents/custodians and other children in the home)

Sr. No.	Full Name	DOB	ETHNICITY	Relationship to the Children
1
2
3
4
5

SECTION III – PERSON(S) ALLEGEDLY RESPONSIBLE FOR THE ABUSE OR NEGLECT

Name
Gender
Ethnicity
BOD
Street Address
City
State
ZIP
Telephone

Name
Gender
Ethnicity
BOD
Street Address
City
State
ZIP
Telephone

SECTION IV – ABUSE OR NEGLECT ALLEGATIONS

(Describe what happened, how it affected the children, and the date(s) occurred, if known.)

Sr. No.	Full Name	DOB	ETHNICITY	Relationship to the Children
1
2
3
4
5

SECTION V - OTHER PERTINENT INFORMATION

SECTION VI - REPORTER

Name
Address
Telephone Number
Title / Agency / Relationship to Children
Did you verbally report the allegations to the Department of Human Resources or law enforcement?

FOR DHR USE ONLY

Country
Case #
Date

Name
Name of County DHR, Police Department, or Sheriff’s Department
Date Reported
Signature
Date

Alert Name	Condition	Alert Action	Available for School Admins	Active/Inactive	Action
ALLEN, Andrew Parker	Attendance : Absent	Email/Popup/Email-SMS
3 ODRs or more	Number of ODRs : 3+	Popup/Dashboard/Alert/Email/Email-SMS