Educational Neglect/Truancy Referral Form
This form is to request services from the Jackson County Attendance Officer due to a student's absences resulting in educational neglect or truancy. If you are not sure if a student should be referred, please reference attendance protocol and contact Attendance Officer.

See link below for attendance protocol:
https://goo.gl/8Cwwks

This protocol needs to be followed before referring a student for educational neglect or truancy.

Today's Date *
MM
/
DD
/
YYYY
Your Name *
Your answer
Your E-Mail *
Your answer
Your Phone Number *
Your answer
Your Role or Title *
School District *
School Building *
Your answer
Student First Name *
Your answer
Student Last Name *
Your answer
Student Date of Birth *
MM
/
DD
/
YYYY
Student Gender *
Student Race *
Student Grade *
Mother/Guardian Name *
Your answer
Mother/Guardian Phone Number *
Your answer
Mother/Guardian Address *
Your answer
Father/Guardian Name *
Your answer
Father/Guardian Phone Number *
Your answer
Father/Guardian Address *
Your answer
Any additional family information. Who does the student live with?
Your answer
Does the student have siblings with attendance concerns? If yes, what are their names and school buildings?
Your answer
Is the student receiving special education services? *
Is the student receiving free or reduced price lunch? *
TOTAL Absences:
Your answer
UNEXCUSED Absences:
Your answer
TOTAL Tardies:
Your answer
Describe any patterns you have recognized with this student's absences.
Your answer
Does the student have a history of attendance issues in previous school years? If so, please describe.
Your answer
Has an attempt been made to contact guardian? *
Include dates of contacts and outcomes of each contact. *
Your answer
Has the school attempted to partner with student's guardian to problem solve and create an action plan to improve attendance? *
If yes, please explain. What was the plan? Did attendance improve?
Your answer
Has the school attempted to utilize school's resources to improve attendance? *
For example, School Counselor, Social Worker, or School Psychologist as appropriate.
If yes, what internal resources were attempted?
Your answer
Has the school attempted to make a referral to an outside community agency? *
For example, Do'Chas, Lifeways, Student Advocacy/Bridges 2 School, Childcare Network, Family Service & Children's Aid, Catholic Charities, etc.
If yes above, what agency was student referred to?
How was the referral made? What was the result? *
Your answer
What is the cause of the attendance problem, if known. *
Check all that apply.
Required
Any additional information you would like to add.
Your answer
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