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Updated August 2005 EP/EXC2 CONFIDENTIAL NOTIFICATION OF FIXED PERIOD EXCLUSION 15.5 – 45 DAYS Schools are required to report details of all exclusions to the LEA (including lunch-time exclusions). In the event of a long single exclusion of 15.5 days or more, this form along with the additional information required should be forwarded within one school day to Pupil Services. If this is impossible please alert us to the exclusion immediately by telephoning: Graham Brammer on 01522 553241. Guidance on the procedure for excluding a pupil can be found in the DfES Paper ‘Improving Behaviour and Attendance: Guidance on Exclusion from Schools and Pupil Referral Units’, issued October 2004. SECTION A: SCHOOL, PUPIL AND PARENT/CARER DETAILS School Name _____________________________________________________________________________ Pupil Surname ________________________________________ Date of Birth ______/______/_______ Pupil Forenames (including middle names)_______________________________________________________ Year Group (Please Circle): N R 1 2 3 4 5 6 7 8 9 10 11 12 13 Male Female UPN _______________________________________ Parents(s)/Guardians 1: Title: (Please circle one) Mr & Mrs / Mr / Mrs/ Miss / Dr Initials: _______________ Status:(Please tick one) Parents Mother Father Stepmother Stepfather Parents Partner Guardian Aunt Uncle Foster Parent Carer Social Worker Other Family member Other Contact Surname: _____________________________________Forename:___________________________________ Address:__________________________________________________________________________________ ___________________________________________________________________ Postcode:______________ Home/Work Tel No:________________________________ Mobile:__________________________________ Parents(s)/Guardians 2: Title: (Please circle one) Mr & Mrs / Mr / Mrs/ Miss / Dr Initials: _______________ Status:(Please tick one) Parents Mother Father Stepmother Stepfather Parents Partner Guardian Aunt Uncle Foster Parent Carer Social Worker Other Family member Other Contact Surname: _____________________________________Forename:___________________________________ Address:__________________________________________________________________________________ ___________________________________________________________________ Postcode:______________ Home/Work Tel No:________________________________ Mobile:__________________________________ Ethnic Group (please see Ethnic Categories sheet) _______________________________________ From whom was the ethnic category derived: Parent? Current School? Former school? Pupil? Any other source? SEN Code of Practice No Special Provision (N) School Action (A) School Action Plus (P) School Action and Statutory Assessment (Q) Statemented (S) Looked After Status Accommodated by Local Authority in voluntary agreement with parent(s) who maintain parental responsibility Subject to a Care Order. Parental Responsibility lies with the Local Authority Remanded to Local Authority Accommodation Social Worker ________________________________________ Tel: _________________________ Updated August 2005 IS THIS A LUNCH – TIME EXCLUSION ONLY? YES NO (If ‘Yes’ complete Section B and D, if ‘No’ complete Section C and D) SECTION B: LUNCH-TIME EXCLUSIONS ONLY Start date of Exclusion _______/_______/______ Last date of Exclusion _______/_______/______ ie the school day before the pupil returns Number of Lunch-times ________ = _______ days (please note 1 lunch-time = 0.5 days) SECTION C: FOR EXCLUSIONS FROM SCHOOL SESSIONS Start date of Exclusion _______/_______/_______ End date of Exclusion _______/_______/_______ ie the school day before the pupil returns Number of school days ________ Does this exclusion mean that the pupil will not be able to sit a public examination? Yes No SECTION D: REASON FOR EXCLUSION Please refer to sheet entitled ’National Standard List of Reasons for Exclusions Tick ONE category only giving the main reason for the exclusion Physical assault against pupil Physical assault against adult Verbal Abuse/threatening behaviour against pupil Verbal Abuse/threatening behaviour against adult Bullying Racist Abuse Sexual Misconduct Drug and Alcohol related Damage Theft Persistent disruptive behaviour Other* *(Please use this category only if none of the others apply and give information below) ________________________________________________________________________________ ________________________________________________________________________________ In addition, did the incident that led to the decision to exclude, referred to above, involve:- An Offensive Weapon (e.g. knife) Yes / No An object used offensively (e.g. stabbing with a compass) Yes / No PASTORAL SUPPORT PROGRAMMES (PSP) / INDIVIDUAL EDUCATION PLAN (IEP) If a Pastoral Support Plan (PSP) has been put in place for this pupil, or if his/her Individual Education Plan has been amended in the light of recent behaviour, please attach a copy. Please be aware that if a PSP is not in place, this should be considered whilst this exclusion is in place. Updated August 2005 Other Agencies currently involved or Referrals made Referral Made Current Main Contact (Please circle) involvement? Emotional and Behavioural SS Yes No Yes No Educational Psychology Yes No Yes No Social Services Yes No Yes No CAMHS Yes No Yes No Youth Offending Team Yes No Yes No Connexions Yes No Yes No Education Welfare Yes No Yes No Police Yes No Yes No Other _____________________ Yes No Yes No If this exclusion is for a pupil in Years 9-13, you must inform the Connexions Local Manager. ADDITIONAL INFORMATION Any known parental views: Relevant Home Circumstances: Would you have any concerns about an LEA Officer making a home visit? Yes No Do not know What are your views about this pupil’s continuing education? What arrangements are being made for the pupil’s education whilst s/he is out of school? Please ensure that enclosed with this form is: A copy of the Headteacher’s letter to Parents/Carers Latest PSP/IEP Signed Date ________________________ (Headteacher/Acting Headteacher) IMPORTANT This form should be completed as fully and accurately as possible and then sent within one school day of the exclusion and by 1st Class Post to: Darren Chapman, Pupil Services Section, Education and Cultural Services Directorate, County Offices, Newland, Lincoln, LN1 1YQ or Fax 01522 553257.
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