To Be Completed at Time of Permanent Exclusion

To Be Completed at Time of Permanent Exclusion

Special Educational Needs and Inclusion Services

NOTIFICATION OF PERMANENT EXCLUSION

To be completed at time of permanent exclusion

Name of School …………………………………………….………...... ……

Contact Person ………………………………………………………………

PUPIL DETAILS
SURNAME / …...... ………………………………………………………………………………
FIRST NAME / ………………...... ………..…....…MIDDLE NAME ……...... ………….……………
ADDRESS / ……………………………………………………………………………………………………………………………
TELEPHONE NO (s) / ……......
UPN / ………………………………………….. /
GENDER Male Female
DATE OF BIRTH / …….…/…….…/………. / NCY GROUP / ……...... / KEY STAGE / …………
IS THE PUPIL LOOKED AFTER? /
YES NO / PEP attached / YES NO
HAVE THERE BEEN ANY CAF / EHA MEETINGS CALLED? / YES NO / LEAD CONTACT PERSON / CONTACT DETAILS
IS THE PUPIL ON A CHILD PROTECTION PLAN? /
YES NO / LEAD CONTACT PERSON / CONTACT DETAILS
DOES THE PUPIL HAVE AN IEP / PSP?
Please attach last available copy of
IEP /PSP / IEP YES NO
PSP YES NO / LEAD CONTACT PERSON
IEP
PSP / LAST REVIEW DATE
IEP
PSP
HAS THE PUPIL BEEN THE SUBJECT OF A MANAGED MOVE? /
YES NO / Name of school attended ......
Last review date ……….…...... Date of breakdown …….....……..
Reason for breakdown ......
DOES THE PUPIL HAVE SEN? (Include details of Statement / EHCP) / YES NO / Details:
IS THE PUPIL IN RECEIPT OF
FREE SCHOOL MEALS? / YES NO
DOES THE PUPIL ATTRACT PUPIL PREMIUM? / YES NO
ETHNICITY (Please tick one box)
Code / Code
  • British
/ WBRI /
  • Indian
/ AIND
  • Irish
/ WIRI /
  • Pakistani
/ APKN
  • Traveller - Irish Heritage
/ WIRT /
  • Bangladeshi
/ ABAN
  • Gypsy/Roma
/ WROM /
  • Any Other Asian Background
/ BOTH
  • Any Other White Background
/ WOTH /
  • Chinese
/ CHNE
  • White/Black Caribbean
/ MWBC /
  • Any Other Ethnic Group
/ OOTH
  • White/Black African
/ MWBA /
  • Refused
/ REFU
  • White/Asian
/ MWAS
  • Any Other Mixed Background
/ MOTH /
  • Traveller
/ TRV
  • Black Caribbean
/ BCRB /
  • Asylum Seeker
/ ASY
  • Black African
/ BAFR
  • Any Other Black Background
/ BOTH
EXCLUSIONREASON (Please tick one box)
PP
PP / Physical assault against a pupil / SM / Sexual misconduct
PA / Physical assault against an adult / DA / Drug and alcohol related
VP / Verbal abuse/threatening behaviour against a pupil / DM / Damage
VA / Verbal abuse/threatening behaviour against an adult / TH / Theft
BU / Bullying / DB / Persistent Disruptive Behaviour
RA / Racist abuse

Have the Police been informed/involved in connection with this exclusion? Yes No

FIRST DAY OUT OF SCHOOL ____/____/____ (Effective date of exclusion)
ATTENDANCE DATA Over the last/current Academic Year ...... %
PARENT/GUARDIAN/CARER DETAILS
TITLE / MR / MRS / MS / MISS
SURNAME / ......
......
......
...... POST CODE ......
FIRST NAMES
ADDRESS
(if different from above)
TELEPHONE/MOBILE / ......
RELATIONSHIP TO PUPIL
Parent Carer Guardian (e.g. grandparents)
Details of any other person with Parental Responsibility:
AGENCIES INVOLVED
AGENCY / Yes / No / Contact Person/and Outcomes
Local Support Team
Child in Need/ Child Protection
CAMHS
YOT
Other: Please Define
STRATEGIES
Support from TutorYES NOPlacement @ LSU YES NO
Learning Mentor YES NOReduced Timetable YES NO
Peer MentorYES NOManaged Move YES NO
School ReportYES NOAlternative Education YES NO
PUPIL ACADEMIC PROFILE
KS2 SATs / Predicted grades / Actual results / KS4 GCSEs / Predicted grades
English / English
Maths / Maths
Science / Science
KS4 additional information
Subject / Exam Board / Course work completed to date (please forward) / Predicted grades
Name of Headteacher...... Date......

Please complete and return the form to:

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