2012-2013

MINNEAPOLIS PUBLIC SCHOOLS

Transfers and Expulsions Phone: 612-668-0844 Fax: 612-668-0845 Email: Expulsions.Transfers@mpls.k12.mn.us MPS EXPULSION REFERRAL STUDENT INFORMATION
Date ______/______/______ School______________________________ Administrator making referral_______________________________

If needed, name of interpreter to be available for meeting________________________________________________

Student Last Name_________________________ Student First Name___________________ ID#_______________ Address__________________________________________ City___________________ Zip Code_____________ Parent/Guardian_____________________________________________ Relationship_________________________ PHONE -- PLEASE BE SURE TO LIST CURRENT PHONES AS WE MUST MAKE CONTACT WITH THE FAMILIES TO SET UP MEETINGS: Phone (h)________________________ (w) _________________________ (cell) __________________________

Date of incident: _____/_____/_____ Date of initial suspension for incident: _____/_____/_____ Total number of days suspended for this incident: _____________ Date student signed buildings Discipline Policy Awareness form ______/______/______ Time of incident: During school hours Outside of school hours Location of incident: Classroom Hallway Locker Restroom Other indoor area School bus Parking lot Other outdoor area (on campus) Off campus Cost to school incurred by this incident: $0 $1-$500 Over $500
Revised 8/8/2012

What type of incident are you reporting? REMINDER CHECK ONLY ONE SUBSTANCE ABUSE Alcohol Tobacco Over-the-Counter Medications against school policy Controlled Substances (prescription) o Possession/Use o Soliciting/Selling Illegal Drugs Was the illegal drug offense for: o Possession/Use o Soliciting/Selling What type of drug was involved? o Amphetamines o Crack/Cocaine o Ecstasy/MDMA o Inhalants o LSD/Psychedelics o Marijuana o Methamphetamines o Other: PHYSICAL Assault o Physical o Sexual Fighting Weapon If weapon, please check appropriate box below. PROPERTY Arson Bomb Possession Computer Pyrotechnics Theft Vandalism/Property Related Robbery Cost associated to any of the above property is: o $250-500 o $501-1,000 o $1,001-5,000 o Over $5,000 OTHER Extortion Bullying Cyberbullying Hazing Harassment o Racial o Sexual o Sexual Orientation o Disability Related o Religious o Unknown Terroristic Threat Bomb Threat Threat/Intimidation

If this incident involved a weapon, what type of weapon: (please include photocopy) Gun: Hand Gun (Loaded? Yes No; Cased? Yes No; In the trunk of a vehicle? Yes No) Pellet/BB/Air Gun Replica/Toy Gun Knife: (please include a photocopy, with the blade edge along a ruler to show the length) More than 2 inches (blade length) Less than 2 inches (blade length) Fire/explosives (please describe):____________________________________________________________ Blunt object (please describe):______________________________________________________________ Other (please describe):____________________________________________________________________

Revised 8/8/2012

Students Disability Status: Did this student have a current, signed IEP at the time of the incident? Yes No Reminder: Does this student have a Section 504 Accommodation Plan? If student has a current, signed IEP at the Yes time of the incident, be sure to send: No o Copy of current IEP Cover Page o Copy of Manifestation Is this student an ELL/LEP? Determination and Team Yes Recommendation No Manifestation Determination Meeting held on: ________ attended by ____________ from Spec. Ed. Monitoring & Compliance Copy of meeting summary is attached.

Student Information: Gender: Male Female Status: Race:

Native American Asian/Pacific Islander Black ; Culture: ____________ White; Culture: ____________

Be sure to check each item!

Non-Student Student of School of Incident Student of Other School Unknown

Grade:______

Date of Birth: ______/______/______

Age:____________

Was supervised homework assigned? Yes (Homework started on ____________ with _______________ as supervising staff person) No Was the student referred to law enforcement? Yes (If yes and student was special ed, IEP with relevant data was faxed to Kim Mesun on _________) No

Revised 8/8/2012