Your name

Title

Student who made threat

School

Date learned of threat

Date threat occurred

Threat reported by (or circle anonymous)

Location of threat

Threat type:    ☐Transient          ☐Serious Substantive    ☐Very Serious Substantive

What student said or did to express a threat (quote student if possible, write exact content of threat):

Interview of Student who made threat

Use interview for investigation; modify and use additional pages as needed and attach to this form.

1. Do you know why I wanted to talk with you?  Tell me.

1. What happened today when you were (refer to place of incident)?

1. What exactly did you say?  And what exactly did you do? (write down student’s exact words)

1. What did you mean when you said/did that? (ascertain the student’s motives/goals)

1. How do you think (target) feels about what you said/did? (determine whether student believes it frightened or intimidated the target of threat)

1. What was the reason you made this threat? (Find out if there is prior conflict or history to this threat, e.g., bullying between the target and the student. Note: Identification of bullying incidents will require an additional investigation, see policy 7:180, Prevention of and Response to Bullying, Intimidation, and Harassment, and exhibits 7:180-AP1, E5, Report Form for Bullying and School Violence and/or 7:180-AP1, E6, Interview Form for Bullying and School Violence Investigation.)

1. What are you going to do now that you have made this threat? (determine whether the student intends to carry out threat)

1. Can you think of a different, more desirable and acceptable, effective way to address this conflict?

Witness Interview   ☐Target of threat  or   ☐Witness to threat, but not target

Use as another component of investigation; modify and use additional pages as needed and attach to this form.

1. Witness name and grade/title:                                    

2. What exactly happened today when you were (Refer to place of incident)?

3. What exactly did (target) you say/do?  (Write down student’s exact words.)

4. What do you think he/she meant when he/she said/did that?

5. How did you feel about what he/she said/did?  Are you concerned he/she might really do it?

6. What was the reason he/she said/did that?

Risk Factors for Violence of Student Who Made Threat

Use these questions when threat is substantive.

1. Family Dynamics

2. Does student have access to guns at home?

3. Is there evidence at home of preparations for an attack at school?

4. What is the home life of the student like?

5. School Dynamics

6. What do we know about the student at school?

7. Does his or her locker harbor a weapon?

8. Was the student angry or brooding when he or she made a threat?

9. What else can be learned?

10. Social Dynamics

11. What do we know about the student’s life in the community?

12. Does he or she have a juvenile record?  Criminal record? Prior station adjustments?  For what?

13. Personal Dynamics

14. What do the student’s closest acquaintances know about him or her?

15. Does the student have a fascination with violent electronic media or weapons?

16. Is the student showing outward signs of the need for mental health services? 

Student Who Made Threat

Target of Threat

Grade:            Gender:  ☐M   ☐F

Race:        

SPED (if applicable):    ☐LD    ☐OHI   ☐MR

            ☐ED    ☐Other:        

Y    N    Had or sought accomplices

Y    N    Reported threat as a specific plan

Y    N    Written plans/list, engaged in attack related behaviors

Y    N    Repeated threat over time

Y    N    Weapon mentioned or used in threat

Y    N    Inappropriate interest in school attacks, attackers, mass violence, terrorism

Y    N    Student’s “story” consistent with actions

Y    N    Student & target had prior conflict (>1 day)

Y    N    Student previously bullied the target

Y    N    Reported threat as a specific plan

# of Targets:        

Primary target:      ☐Student   ☐Teacher

☐Administrator    ☐Parent     ☐ Other

Grade:            Gender:  ☐M   ☐F

Race:        

SPED (if applicable):    ☐LD  ☐OHI ☐MR

            ☐ED  ☐Other:        

Y    N    Target witnessed threat

Y    N    Target  previously bullied the student

Y    N    Student previously bullied by target 

Y    N    Concerns about student’s potential to carryout act or potential for violence

Y    N    Target(s) previously bullied the student

Threat Responses  (Management and prevention)

Disciplinary Action

Y    N    Parent conference

Y    N    In school time-out

Y    N    Detention (# of days):        

Y    N    Suspension (# of days):        

Y    N    Expulsion recommended

Y    N    Other response

Interventions and Safety Precautions

Y    N    Law enforcement consulted

Y    N    Law enforcement contact with student who made threat

        Consequence of legal action (Station adjustment, supervision, conditional discharge, adjudication of delinquent minor,  release into parents custody)

Y    N    Student might be eligible for special education services, referred for evaluation

Y    N    Student already receiving special education services, referred to IEP team for review

Y    N    Student referred for 504 plan

Y    N    Mental health assessment conducted by school-based staff

Y    N    Mental health assessment conducted by outside agency (court, Dept. of Probation, DCFS, other psychologist)

Y    N    Parents of threat target notified of threat

Y    N    Conflict mediation

Y    N    School based counseling

Y    N    Alter student’s schedule to increase supervision or minimize contact with target

Y    N    Alternative educational placement (alternative school, day treatment program)

Y    N    Change in transportation (bus suspension, special transportation, etc.)

Y    N    Inpatient mental health services

Y    N    Outpatient mental health services (counseling/therapy with outside mental health provider)

Y    N    Other mental health services 

Y    N    Other safety precautions (if yes, please list them.)