DAEP PLACEMENT FORMS (ELEMENTARY SCHOOLS)

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1 DAEP PLACEMENT FORMS (ELEMENTARY SCHOOLS)

2 LAREDO INDEPENDENT SCHOOL DISTRICT Disciplinary Alternative Education Placement Packet Administrator Checklist for Elementary Schools Campus: Student: DOB: ID#: Grade: Administrative Forms: Principal s Due Process Conference Form Disciplinary Alternative Education Placement Letter All Pertinent Data (e.g. Incident-Accident Report, Police Report, Voluntary Written Statements," Under the Influence" checklist) Student Files: Student Discipline Action Form Counseling Referral Form (Required for Discretionary DAEP Placements) Discipline Intervention Documentation Form (Required for Discretionary DAEP Placements) Special Education students: (if student has been removed through short term removals from the specified instructional setting for more than 10 days) Hold ARD within 10 school days to take this action Manifestation Determination If ARD is not held within the days of suspension, student must return to home campus. Home campus is responsible for not changing placement (ISS, suspension, etc.) for more than 10 days. Two (2) BIPs (created, revised, modified, etc.) addressing the specific behavior involved in the referral. Complete ARD packet including the following: Manifestation Determination page (Place at beginning of ARD packet) FBA (Functional Behavioral Assessment) Manifestation Determination Review meeting (MDR) for this offense BIP (Behavior Intervention Plan) from Manifestation Determination Review Meeting (MDR) for this offense Schedule of services (be sure to include only courses that are offered at F.S. Lara) IEP Section 504 Students: Manifestation Determination Copy of Individual Accommodation Plan Individual Behavior Management Plan Note: Three copies (original plus 2 copies of packet) must be delivered to the Director of Student Hearings. We MUST receive your packets no later than 24 hours following the Due Process and assignment. *** All packets must be completed and properly signed and/or documented to be accepted. *** Prepared by Date LISD Official Form Last Updated July 2008

3 LAREDO INDEPENDENT SCHOOL DISTRICT Principal s Due Process Conference Campus: Conference Date: Student: I.D. #: Grade: D.O.B.: Student Status: Regular Ed Special Ed ESL Previously Placed in AEP 504 LEP Mainstream Parents/Legal Guardian: Address: Zip Code: Work Phone: Home Phone: Parents were notified of Conference on Date by Administrator Offense: Proposed Disciplinary Action: Comments: Conference was conducted in English Spanish I certify that the Principal s Conference was conducted in compliance with state and local policy and that all safeguards for the student s due process rights were extended. Parents/Legal Guardian Signature Date Administrator s Signature Date Student s Signature Date Interpreter s Signature Date LISD Official Form Last Updated May 2004

4 DISCIPLINARY ALTERNATIVE EDUCATION PLACEMENT LETTER date enter parent(s) name enter street address Laredo, TX enter zip code Dear enter Mr. and Mrs. + last name: This letter is to inform you that your son or daughter, enter student's full name and I.D. #, has been placed in a Disciplinary Alternative Education Program at enter name of home campus, for the following reason(s): list offense(s) on enter date enter time enter place Your son or daughter shall be removed from his or her regular classroom beginning on date DAEP begins and shall continue to receive educational services for number of days school days. A copy of the Disciplinary Alternative Education Program placement packet will be delivered to the Webb County Juvenile Department as mandated by the Texas Education Code under Section Should you wish to contest your son's or daughter's placement, you may contact the office of the Hearing Officer at , to arrange a review hearing. Any decision by the Hearings Officer is final and non-appealable. Note: A student who transfers out of LISD to another public or private institution (including a student who is withdrawn for the purpose of home schooling) during the period of Alternative Education Placement shall be required, upon return to LISD, to complete the number of days missed in the Disciplinary Alternative Education Program, before being allowed to return to the campus. Should you have any further questions regarding this matter, please do not hesitate to contact me. Sincerely, Principal Campus name xc: Hearings Officer Webb County Juvenile Case Management Director LISD Official Form Last Updated August 2009

5 fecha Sr. y Sra. dirección Laredo, TX. zip code Sr. y Sra. (last name): Esta carta es para informarle que su hijo o hija, student full name and I.D. #, ha sido colocado o colocada en un programa de educación alternativa disciplinaria por la siguiente razón: list offense(s) en enter date enter time enter place Su hijo o hija será asignado a este programa de educación alternativa disciplinaria, empezando el día enter date DAEP begins y allí seguirá recibiendo éstos servicios educacionales por enter number of days días escolares. Se mandara una copia del paquete de colocación del programa de educación alternativa al departamento juvenil del condado de Webb como es el mandato del código de educación de Texas bajo la sección Si su hijo o hija no asiste a este programa de educación alternativa disciplinaria, durante el término asignado, el estudiante tendrá que reponer el número de días ausentes en el programa antes de poder regresar a su salón de planta. Nota: Un estudiante que se transfiere o se cambia a otra institución pública o privada fuera del distrito de LISD (incluyendo un estudiante que se ha retirado para seguir sus estudios en casa) tendrá que, como requisito, regresar al distrito y completar el número de días ausentes en el programa de educación alternativa disciplinaria, antes de poder regresar a su escuela de planta. Si desea apelar el cambio de su hijo o hija al programa de educación alternativa disciplinaria, puede comunicarse a la oficina del Director de Audiencias de Disciplina, al número , para hacer arreglos para una audiencia de revisión. La decisión del Oficial de Audiencias, el funcionario a cargo de la audiencia, será final y no es apelable. Por favor tome nota de que mientras su hijo o hija esta en este programa, no puede participar en ningún tipo de actividad escolar ya sea patrocinada o relacionada con las escuelas. Al completar el término en el programa de educación alternativa disciplinaria, su hijo o hija podrá regresar a su escuela de planta. Si tiene alguna pregunta respecto este asunto, por favor llámeme. Sinceramente, Principal's name School Name xc: Hearings Officer Webb County Juvenile Case Management Director LISD Official Form

6 Last Updated August 2009 LAREDO INDEPENDENT SCHOOL DISTRICT VOLUNTARY STATEMENT I,, agree to making this statement at (Last Name) (First Name) as a reporting party victim witness, on a voluntary basis before on this day of 200 at o clock in Laredo, Webb County of Texas. My name is. My address is in (City) (County) (State) my date of birth is and my present age is my home telephone number is ( ). I m employed by in the capacity of business phone number is ( ). This statement is in reference to Details of Statement LISD Official Form Last Updated May 2004

7 Signature Date

8 Health Services Department INCIDENT ACCIDENT REPORT 1. Name Home Address 2. Sex: M F Age: DOB School Teacher 3. Time of accident: Hour a.m. p.m. School Insurance: Yes No 4. Status: Teacher: Student: Other: 5. Place of accident: School building School grounds To or from school Interscholastic athletics 6. Apparent Nature of Injury Abrasion Fracture Amputation Laceration Bruise Puncture Burn Scratches Cut Sprain Other (specify) Description of Accident and Treatment Given How did the incident/accident happen? What was the person doing? Where was the person? List acts and conditions existing. Specify any tool, machine, or equipment involved. Description: 7. Part of Body Injured Ankle Hand Arm Head Back Knee Elbow Leg Eye Nose Face Scalp Finger Tooth Foot Wrist Other (specify) Witness s Name Address Phone: 8. Immediate Action Taken First aid treatment Sent to school nurse Sent home Sent to physician Sent to hospital By (name) By (name) By (name) By (name) Physician s name By (name) Name of hospital How was the person transported? Was the parent or other individual notified? No Yes When? How? Name of individual notified: By whom? (enter name) Were Protective Devices Used? Safety Measures Involved: Any Safety Measures to be Implemented: 13. Location Specific Location Athletic Dressing room School grounds Auditorium Gymnasium Shop Classroom Home Economics Showers Corridor Laboratories Stairs Cafeteria Other Follow-up Total number of days lost from school (To be completed when person returns to school.) Date Signature of Teacher or School Nurse Date Signature of Authorized School Official Copy of form to be submitted to principal. 08/03 DHS A

9 Observation Checklist for Administrators Under the Influence Campus: Student s Name: ID# Grade Time: a.m. p.m. Address Age DOB Date: Phone: UNDER THE INFLUENCE: means not having the normal use of mental or physical faculties; however, the student need not be legally intoxicated. Impairment of a person s physical and/or mental faculties may be evidenced by a pattern of abnormal or erratic behavior and/or the presence of physical symptoms of drug or alcohol use. (LISD Student Code of Conduct, Board Policy FNCF (Local) Please check all that apply: Speech: Clear Slurred Rapid Behavior: Quiet Apathetic Withdrawn Drowsy Dazed Yawning Lethargic Nervous Restless Irritable Shaky Over-reacts (without cause) Aggressive Agitated Anxious Argumentative Relaxed Cooperative Attentive Alert Talkative Silly Euphoric Dizzy Laughing (without cause) Cognitive Level: Normal use of mental facilities Coherent Confused Oriented to person Oriented to place Non-communicative Gait: Normal use of physical facilities Staggering Wobbling Clumsy Eyes: Bloodshot Tearing Glazed Other Comments: Name of Administrator: Signature: Date: LISD Official Form Last Updated May 2004

10 STUDENT FILE

11 LAREDO INDEPENDENT SCHOOL DISTRICT Campus: STUDENT DISCIPLINE ACTION FORM Regular Ed Special Ed 504 Student: ID#: Grade: DOB: Parent/Guardian: Address: Home Phone: Work Phone: INCIDENT : PEIMS: Number Date Time Location Reason Action Table (C165) Table (C164) *** PEIMS Codes must be entered in the 425 Report prior to submitting paperwork. *** Excessive Absences/Tardies LEVEL I - MINOR OFFENSES LEVEL IV EXPELLABLE OFFENSES Cheating/Lying/Deceitfulness Using/Exhibiting/Possessing Firearm Illegal Knife Excessive Absences/Tardiness Aggravated assault against a school district employee/volunteer Classroom/Campus/Bus Misbehavior Aggravated assault against someone other than a school district employee/volunteer Disrespectful/Impolite Sexual assault or aggravated sexual assault against a school district employee/ Leaving Class/Campus/School Activity Without Permission volunteer Inappropriate Verbal/Physical Conduct Sexual assault or aggravated sexual assault against someone other than a school Possession/Smoking/Using Matches/Lighter/Tobacco district employee/volunteer Violating Dress/Grooming Code Arson Using Electronic Device (Pager/Cellular Phone) Murder, capital murder, criminal attempt to commit murder or capital murder Other Indecency with a Child Aggravated kidnapping Aggravated robbery Manslaughter Criminally negligent homicide FOLLOWED DISCIPLINE PLAN yes no Felony controlled substance violation Teacher s Comments: Felony alcohol violation Criminal mischief Other LEVEL II - SERIOUS OFFENSES Vandalism On School Property Student Property Stealing/Theft Insubordination Disrespect/Profanity/Vulgar Language/Gestures Towards School Employee Witnesses: Fighting Falsifying Documents/Records Possession/or conspiracy to Possess any Explosive Device Making/Assisting in Making Threats (Individual) Placing a Prohibited Substance in Another Person s Food/Drink and/or other possessions Possessing/Selling Drug Paraphernalia/Look-A-Like Drugs ACTION TAKEN (TABLE 1096) (Administrator Use Only) Participating in Gang-Related Activities Misuse of Computer/Software/Internet Verbal Reprimand Other Teacher Conf. W/Student/Parent LEVEL III DISCIPLINARY ALTERNATIVE EDUCATION PROG. Counselor Conf. W/Student/Parent False alarm/false report Administrator Conf. W/Student Parent Making/Assisting in Making Threats/Terroristic Threats Telephone Call or Note to Parent Felony on Campus Detention AM PM Lunch Saturday Assault against someone other than a school district employee/volunteer Withdrawal of Privileges Assault against a school district employee or volunteer ISS Day(s) in School Suspension AP1 Selling/Giving/Delivering/Possessing/Using Suspension from School Day(s) look alike drug marijuana other Assignment to Off-Campus AEP Days AP2 Selling/Giving/Delivering/Possessing/Using Alcohol Other Abuse of a volatile chemical PD Citation Case No. Engaging in Public Lewdness/Indecent Exposure Retaliation Against a School Employee Title 5 Penal Code Felony Criminal Mischief Other Administrator s Comments: NOTE: Students assigned to In-School Suspension shall serve the prescribed day(s). Absence(s) shall not exclude student from In-School Suspension Placement. Originator Date Administrator Date LISD Official Form Last Updated July 2008 Student Date Parent/Guardian Date

12

13 Counseling Referral Form Priority Level Low Moderate High Student I.D. # Grade Referred By Date Homeroom Teacher (Elementary Only) Reason for referral: Poor peer relationships Behavioral problems Academic problems In need of Social Services PEP (Parenting Ed. Program) Family changes (death, divorce, re-marriage, moving, etc.) Extremely withdrawn Sudden changes in mood, attitude, or behavior Other (Please Specify) Services provided to student by School Counselor: Name of Curriculum used (i.e. Anger mgmt. Gang Prev., Violence Prev., etc). Date Counseled: ********************************************************************************************************************** Name of Curriculum used (i.e. Anger mgmt. Gang Prev., Violence Prev., etc). Date Counseled: ********************************************************************************************************************** Name of Curriculum used (i.e. Anger mgmt. Gang Prev., Violence Prev., etc). Date Counseled: ********************************************************************************************************************** Name of Curriculum used (i.e. Anger mgmt. Gang Prev., Violence Prev., etc). Date Counseled: ********************************************************************************************************************** Date Counselor s Signature LISD Official Form Last Updated May 2004

14 LAREDO INDEPENDENT SCHOOL DISTRICT DISCIPLINE INTERVENTION DOCUMENTATION FORM FOR DISCRETIONARY PLACEMENTS Student Name: D.O.B.: I.D.#: Date Submitted: Campus: Teacher s Name: Grade: Counselor s name: Administrator/Counselor Signature: Regular Ed. Special Ed 504 Signature of responsible person: Behavior Concern: Description Signature of responsible person Interventions Implemented (i.e., Campus Support Team, Counseling, Intervention Outcome Parent Conferences, Truancy Court, Gang Activity, etc.): Dates LISD Official Form Last Updated May 2004

15 SPECIAL EDUCATION

16 SECTION 504 STUDENTS

17 Laredo Independent School District Manifestation Determination Student: ARD Date: Behavior subject to disciplinary action: Disabilities: The ARD Committee has reviewed all relevant information, including evaluation and diagnostic results, observations of the child, the current IEP and placement, and other relevant information supplied by the parents. Based on this review, the ARD Committee has made the following determinations: 37. In relationship to the behavior subject to discipline, the IEP and placement were appropriate and the special education services, supplementary aids and services and behavior interventions strategies were provided consistent with IEP and placement. YES NO 38. The child s disability/ies did not impair the ability of the child to Understand the impact and consequences of the behavior subject to Discipline. YES NO 39. The child s disability/ies did not impair the ability of the child to control The behavior subject to discipline, YES NO NOTE: IF ANY OF THE THREE DETERMINATIONS ARE ANSWERED NO THEN THE BEHAVIOR MUST BE CONSIDERED TO BE A MANIFESTION OF THE STUDENTS DISABILITY, IN THAT EVENT, THE STUDENT CANNOT BE EXPELLED OR PLACED IN THE DISTRICT S AEP BEYOND 10 SCHOOL DAYS.

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