NOTIFICATION OF PERMANENT EXCLUSION To be completed and returned on the day of permanent exclusion to: Inclusion@staffordshire.gov.uk (This will enable the LA to provide the Alternative Provision from Day 6 from the permanent exclusion) Name of School Dfe No Contact Person/ Position Contact Tel Number/ Email: Please specify with x if your school is:- Academy Maintained School Special School PRU Other (please specify) Pupil Details Surname First Name Middle Name: Address Postcode Telephone No UPN Gender (please specify with x) Male Female Date of Birth --/--/---- NCY Group Key Stage Parent / Guardian Carer Details Parent / Guardian / Carer Details – (Please specify with x) Parent Guardian (e.g Grandparents) Carer Title Mr/ Mrs / Miss /Ms Surname First name Full Postal Address (if different from above) Are there any issues with home visiting this family that you are aware of. Yes No Please provide any relevant details. Please specify details of other person with Parent responsibility (with address if not same as above). Are there any known risks to the family preventing us from confirming this permanent exclusion to the other person with parental responsibility Yes No Parent / Guardian / Carer Details – (Please specify with x) Parent Guardian (e.g Grandparents) Carer Title Mr/ Mrs / Miss /Ms Surname First name Full Postal Address (if different from above)
Telephone No Comments Is the Pupil a LAC Yes No Have been any CAF / EHA meetings called Yes No Is the Pupil on a Child Protection Plan Please specify Lead Contact person and tel no. Yes No Contact: Telephone: Does the pupil have an IEP / PSP. If yes please attach last available copy of IEP/PSP Yes **School to include PSP/IEP Plan No Contact: Telephone: Has the Pupil been the subject to a Managed Move. If yes please provide the following Information:- Yes No Name of School: Last Review Date: Date of Breakdown: Reason for Breakdown: Does the Pupil have an SEN – Please specify SEN type Yes No Does the Pupil have an EHCP Plan? Yes/No Please attach a copy of the most recent if yes SPLD/MLD/SLD/PMLD/ASD/HI/VI/MSI/PD/ (Please specify) Does the pupil currently receive in class support? Yes No Details: Frequency/subject/hours: If the Child has an EHCP Plan – please provide Keyworker Name and Contact Number Key Worker Name Contact Number Is the pupil in receipt of Free School Meals Yes No Does the pupil attract Pupil Premium Yes No Ethnicity (Please tick one box) British WBRI Indian AIND Irish WIRI Pakistani APKN Traveller - Heritage WIRT Bangladeshi ABAN Gypsy/Roma Any Other Asian Background BOTH Any Other White Background WOTH Chinese CHNE White/Black Caribbean MWBC Any 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 Exclusion Reason (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 OT Other