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Confidential EXC

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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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