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Dodge City Public Schools

SAFETY AND SECURITY SAMPLE FORM - REPORT TO STAFF (LINK TO EBC)

SAFETY AND SECURITY REPORT TO STAFF MEMBER Sample Form

EBC   SAFETY AND SECURITY REPORT TO STAFF MEMBER

– Sample Form –

Retype to suit local needs, remove from policy book and file with the clerk and principals.  Form could also be included in staff or student handbooks.

Safety and Security Report to Staff Member Form - Printable Version

Report to Staff Member USD 443

Pursuant to K.S.A. 72-6143, administrative, professional or paraprofessional employees of a school who have information that a pupil has engaged in the following shall report the information and the identity of the student to the superintendent.  The superintendent shall investigate the matter and if it is determined the student has been involved in the following, the superintendent shall provide information, and the identity of the pupil to all employees who are involved or likely to be directly involved, in teaching or providing related services to pupil:

  1. Any student who has been expelled for conduct which endangers the safety of others; 
  2. Any student who has been expelled for commission of felony type offenses;
  3. Any student who has been expelled for possession of a weapon;
  4. Any student who has been adjudged to be a juvenile offender and whose offense, if committed by an adult, would constitute a felony,   except a felony theft offense involving no direct threat to human life;
  5. Any student who has been tried and convicted as an adult of any felony, except theft involving no direct threat to human life.

You are notified that ________________________, within the past 365 days, has been expelled, adjudged or convicted for an activity listed above.

School District staff are required by both Federal Law and K.S.A. 72-6311 to protect the right of privacy of any student under the age of 18 and the student's family regarding personally identifiable records, files, data and information directly related to the student and his/her family. I acknowledge this responsibility and agree that I will disclose the above information only to other USD 443 employees and officials. Violation of these privacy rights could include sanctions up to and including termination.

 

Signed:________________________________________________________ School employee who receives the report

Signed:________________________________________________________ Administrator or school employee making report