START Administrator Survey (Student Name in Email)

Concern for the following student has been brought to the attention of the Student Assistance Team. Please note your observations on this form. This information will be used to help the student and his or her family to clarify the concern and determine an appropriate action.
Name: 


A red asterisk (*) indicates required questions.

  1. Your identity will not be seen on the collected data print out, or disclosed to the parent/student. Would you prefer a member of the Student Assistance Team to contact you instead of completing this form?*
    Yes, please contact me.
    No, I will complete this form.


  1. Please attach attendance information from Infinite Campus.

    In the space below, please list any truancy citations (include date):


  1. Number of detentions:


  1. Number of out-of-school suspensions:


  1. Number of in-school suspensions:


  1. Have you had contact with outside agencies that are working with this student (i.e. probation, children and youth)? Please describe the nature of the contact:


  1. Please check all that you have observed about this student.

    Student Initiated Requests:
    Bullying victim
    Help with home problem
    Help with financial problem
    Other (explain in details)


  1. Please explain any details from the Student Initiated Requests section:


  1. Policy Violations
    Assault
    Fighting
    Dress code
    Terroristic threats
    Possession and /or use of tobacco
    Possession and /or use of alcohol
    Possession and /or use of other drugs
    Possession and /or use of drug paraphernalia
    Possession of beeper, cell phone, or other electronic device
    Involvement in theft
    Vandalism
    Bullying others
    Harassment (explain in details)


  1. Please explain any details from the Policy Violations section:


  1. Types of Interventions
    Student conference
    Parent conference
    Student and parent conference
    Referral for special services- child study, 505, spec ed. (explain in details)
    Other (explain in details)


  1. Please explain any details from the Types of Interventions section:


  1. Other Disruptive or Inappropriate Behaviors
    Obscene language or gestures
    Verbally abusive
    Repeated class cuts
    Sleeping in class
    Sudden outburst of anger
    Distrubing other students
    Denying responsibility, or blaming others
    Distractible
    Easily influenced by others
    Repeated dress code violations


  1. Other
    Expresses desire to punish or gain revenge, via harmful or deadly means
    Expresses alcohol and other drug use openly
    Expresses involvement in hate groups
    Loss of co-curricular eligibility
    Possession of large amounts of money
    Suspicion of alcohol / drug use (list observations in details section)


  1. Please write your specific observations regarding your suspicion of alcohol / or drug use:


  1. In the space below, please provide any other observable behavior or information you deem appropriate to the referral:





Mrs. Graham
Science Teacher
Central Bucks HS South
Doylestown, PA