Oakland County Early Truancy Intervention Program Referral Form

Oakland County Early Truancy Intervention Program Referral Form This Form Must Be Filled Out Completely Before It Can Be Processed DO NOT E-MAIL THIS FORM, by law it must be sent by a secure fax or mailed (interschool or US mail). To facilitate the processing of this referral, complete ALL items on this page, retain a copy for your file and return the original to Sharon Leeper, Oakland Schools, 2111 Pontiac Lake Road, Waterford, MI 48328-2735. (Phone: 248.209.2142; Fax 248.209.2202) Truancy/Attendance Officers, Bill Conley (248.209.2560) and Lisa Krapohl (248.209.2303) No Nicknames Please Child’s Name: DOB: Sex: Home Phone: (248)______School: District: Grade: School Phone: (248)______School Address: City: Zip: 48______Father’s Name: Mother’s Name:______Address: Address:______City: Zip: 48 City: Zip: 48______Phone Nos. (home, work, cell) Phone Nos. (home, work, cell) (248) ______

Please complete shaded area below in the following manner: * = 1st day in school \ = Absent AM only / = Absent PM only X = Absent all day O = No School Aug 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Sep 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Oct 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Nov 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Feb 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Mar 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Apr 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 May 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jun 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

1. Initial contact was made with parents/guardian and child to discuss the problem. ______Yes ______No Dates: 2. Conference was held with parents/guardian, child and appropriate school personnel. ______Yes ______No Dates: 3. Action plan was developed. ______Yes ______No Date: Attach plan if applicable. 4. Resources utilized by school: ______Assistant Principal ______School Psychologist ______Family Crisis Intervention ______Social Services ______Physician ______Youth Assistance ______School Counselor ______Other (describe) 5. The student is special education. ______Yes ______No 6. The absences are due to: ______Illness ______Suspensions ______Other ______7. There is a history of attendance problems in prior grades. ______Yes ______No (If yes, list grades and number of absences. ______8. The student is achieving academically. ______Yes ______No

Authorized Signature ______Title______Date ______

C:\Pupil Personnel Services\ETI Referral Truancy

Oakland County Truancy Protocol

Bill Conley and Lisa Krapohl

Bill Conley, Truant/Attendance Officer Oakland Schools 248 209-2560

Lisa Krapohl, Truant/Attendance Officer Oakland School 248 209-2302

Sharon Leeper, Truancy Office Assistant Oakland Schools 248 209-2142

Website: www.oakland.k12.mi.us (To access information on truancy, go to the Oakland Schools website, then go to Quick Links [upper right corner] and select Truancy.)