Education Neglect and Truancy Referral

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Referral Information

Referral Type

Referral Date

Number of Days with an Unexcused Absence

Is student at risk of a 15 day drop?

NoYes

15 Day Drop Date

Date 3-Day Mandatory

What specific academic concerns would you like to address?

Is this student a transfer from another county?

NoYes

Please specify the county the student is transferring from:

Unexcused absences are largely/solely occurring while the student is physically in the building?

NoYes

What efforts has the school made to address in-school truancy concerns?

AIM Information - Only complete this section for students 12 and over

Date Referred to AIM

Did the child attend AIM

Student Information

First Name

Middle Name/Initial

Last Name

Date of Birth

Grade

Gender

Race

Parent/Guardian Information

Lives With?

School's Primary Contact

Mother's/Legal Guardian's Name

Mother's/Legal Guardian's Phone

Mother's/Legal Guardian's Email

Address

City

State

Zip Code

Fathers Address Same as Mothers

NoYes

Father's/Legal Guardian's Name

Father's/Legal Guardian's Phone

Father's/Legal Guardian's Email

Address

City

State

Zip Code

Interpreter needed?

The school is responsible to schedule an interpreter for the meeting

NoYes

Primary Language

Attendance Barriers - Are you aware/suspicious of any of the following barriers to attendance for the student? Please provide details

School Efforts: Please fill in details after each statement below. Inadequate efforts or information may result in a delay or screen out of the referral.

Has school staff engaged the student after unexcused absences to understand reasoning for absences?

Has school staff met with parents and student to discuss absences?

Have parents been contacted on each day of absence (not robocall)?

If parents have been unable to be reached, has emergency contact been utilized?

Has the school attempted/made home visits?

Has assistance of the SRO/Law Enforcement been used for welfare check?

Has an explanation of attendance laws been provided to parents?

Has an attendance/behavior plan been completed with the student?

Have incentives/rewards been offered for good attendance? What kind?

Has the student been referred to outside community programs? Which ones?

Has the student been provided with a modified homework schedule?

Arranged student visits with school counselor?

Have alternative programs been reviewed with student and parents (eg. ALC)?

Has tutoring or academic mentoring been offered or attempted?

Has the student engaged in any school based social or peer support groups?

Does the student participate in extracurricular activities or have they been encouraged to do so?

Has transportation assistance been offered or provided?

Has the student been offered a modified class schedule?

Has there been confirmation that technology is available and accessible?

Has a school based mental/chemical health referral been made?

Please list any other interventions that the school has provided:

Have attendance expectations been clearly communicated to the family?

NoYes

How / why not?

Academic / Behavior / Special Education

School Information

Name of School

Official and Title

Official's Phone

School Address

School City

School State

School Zip

School Confirmation email

To receive a confirmation email and to schedule the meeting

Name and title of person completing form

If the student is supported by other school personnel (SPED CM, Check and Connect, SRO, Specialists, Student Advocates, etc,) Please invite them to the meeting.

All meetings will be held in person unless specifically requested below.

Please upload the student's current attendance records. If attendance records are not included, the process will be delayed.You can upload a maximum of 1 file, up to 90MB.

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Washington County - MN

Education Neglect and Truancy Diversion referral

Referral Information

AIM Information - Only complete this section for students 12 and over

Student Information

Parent/Guardian Information

Attendance Barriers - Are you aware/suspicious of any of the following barriers to attendance for the student? Please provide details

School Efforts: Please fill in details after each statement below. Inadequate efforts or information may result in a delay or screen out of the referral.

Academic / Behavior / Special Education

School Information

Education Neglect and Truancy Diversion referral

​​Referral Information

​AIM Information - Only complete this section for students 12 and over

Student Information

Parent/Guardian Information

​​​​Attendance Barriers - Are you aware/suspicious of any of the following barriers to attendance for the student? Please provide details

School Efforts: Please fill in details after each statement below. Inadequate efforts or information may result in a delay or screen out of the referral.

Academic / Behavior / Special Education

School Information

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Referral Information

AIM Information - Only complete this section for students 12 and over

Attendance Barriers - Are you aware/suspicious of any of the following barriers to attendance for the student? Please provide details

You’re over the file size limit

File upload limit reached

Unsupported file formats