iv Threat Assessment Inquiry-District 77 "This tool is for use by the School-based Threat Assessment Team to aid in the determination of recommendations to the Principal for students who may pose a potential threat to themselves or others. A minimum level of team ‘members would include Prineipal/ or Assistant Principal, Schoo! Psychologist, Schoo| Counselor, and a teacher with significant knowledge about the student (i.e. homeroom teacher or case manager) This tool is to be used by trained Threat Assessment Team members. There is no exact method to determine a student’s violent ideation or tendencies. One or more of these warning signs may be displayed before a person becomes violent, but does not necessarily indicate that an individual will become violent. Use this tool to help guide your screening process and intervention recommendations. It is important to attain multiple sources of information to fully complete the screening, Ifat all possible, interviews should include the student making the threat, one or more teachers who know the student, and parents of the student, Signature of Investigating Administrator: Background Information: Schoo! Kenvidy Clementary School Phone |(507) 38 7-|Q/22 t ane | Student Phone Suc’ | gummmmmmmmmmm | 2 Age Dave of bith 72971860 — Q & B29 Accs | nde Mamlato Sue [PIN] 2 | 500] be collected by team, and team reconvene for Date forTA | Y /a//QoAs” nt Determination jon of threat assessm The parent/guardian has been notified of this assessment by administrator by phone—Date: Letter to follow—date: Threat Assessment Team Member Assignments: 1 fam hort ~ School _ £5: chalooist 2, Cour. Samual son - Special, Aducctn ea 3 Maney Koch — School Comnsehar School Sociol bor ber 4 [ane Lvewsor~ chu 5 Following adapted from a 2002 checklist of Melissa E, DeRosier, Clinical Psychologist, a survey of existing research and literature. This checklist was modified by District 77, Fall 2007 to reflect United States Secret Service (National Threat Assessment Center) and US Department of Education (Safe and Drug-Free Schools) Joint Study Document of 2004.J hurt sh f ot VG Incident Description: (complete all felts) neg ok were DeaibeTel TO a Hacked email (exact words, if sont} [KVerbal threat 0 Written threat 3xPhysical act pueortuca [4/4 # | romortien [tinimidaton O Presented asjoke U0 Vell orindieets Ws. Other _ Who was the [pxStudent(s) (Who? Toward rimsel+ eS target of the [C1 Adult(s) (Who? secres (what Koni fe— ) NOTE; The resulls ofthis screening do not predict future violent behavior nor are they a foolproof method of assessing an individual's risk of harm to others, ‘The purpose of this screening is to identify the factors and circumstances that may | increase risk for potential youth violence as well as to assist the school staff in developing the management recommendations, Use interview data with multiple informants, Including the threat maker, to determine whether each of the following factors is present. Multiple forms may be used fo collect data, but one form should be used to indicate collective team data, All forms should be turned in to principal after inquiry is completed. If an item is true according to any source, ‘mark that item true, Ifthe item remains unclear despite assessment, mark UC (Unclear), ritieal Factors Factors related to threat : True [False [UC [Info/Describe If there was a plan, it was premeditated and deliberate (not impulsive) No steps oF & pla TF there was a plan, i included @ weapon Ente, TF the plan involved a weapon, it was accessible 4 at PX SE ‘Others were aware of the plan | ‘Student communicated the plan to others — TOL Gt Indications of plan to hurt sci Gnuding suicidal ideation) Rehearsal of attack Joc fatemeserive Aoes rk eypress ren} [Factors related to threat maker's cognitive state’: [rrue [False [Expresses no regret for making the threat, does not apologize [Expresses continued intent to carry out the threat ‘Blames others, does not take responsibility for making threat «x 1 Feels justified in having made the threat % FES, Cbe=d| ‘Sees violence as a method of effective problem-solving ‘Sees making the threat as appropriate Continues to express anger or defiance ‘Expresses making the threat in retaliation or self-defense Teal?” | OScoo! Trae adhe [OD wage : < Sie [anagem sald Gfacternnt alond iy fout of am OT Patou pcr wha as notte rg (Whe Pahedltencl, ‘Who reported the [0 The target Samed so, eee non eegted aduh()(whor_ Coren. Samust son 5 sor (A non-targeted peer(s) (Who? 4) _| Didthetven [RNO — Nota plan baka weapen (Net Awe Wor ‘an includea plan? | [] YES Did the plan include a weapon? 1] NO On - as[Factors related to threat maker’s history and emotional state’: [re rate fre [nfo/Deseribe |weztession/chavior Prior incidents of serious threats or violence SOE ‘Student has access to firearms History of fascination with weaponry or violent acts (including in drawings and writings) posh gon ‘Student has a history of threatening others [Benn ot History of conflict between the student and those threatened Depression/Suicidal ‘Student shows signs of depression, or hopelessness ‘Student expresses suicidal ideation cial Difficulties ‘Student has history of being bullied or teased “Hows, PRS Riek hey Perception of being treated unfairly pes PAE Student sees self as a vietim of chronic teasing or bullying History of grievances or grudges Vee end eth ‘Student reports that there is NO adult at school with whom he/she has a close relation ont Slob ms Bs, belve she: ‘hi ‘Student has experienced significant loss or emotional trauma within last 6 ‘months (such as loss of gieliiend, parents divorced, friend moved away, humiliation, rejection, death of friend or parent, disciplinary action) x |« Heh Motives: (Je, Revenge, attention, recognition, desire to die, see no other answer to a problem) a sees no Othe to ote Other: 2 he primary source ofthis infomation wil be the interview withthe threat msker, though other sources of information may also be useful Dig orderto ase these the student well inthe screening proces. fis recommended that you include he tet mask, hsher paren, ad atleast one teacher or ther school slat who knows[\dditional Possible Contributing Factors’: True [False [UC |info/Deseribe ] [Behavior Stents generally aggrssve aero settings choo home, Comms —) salt anges tare Flistory ides conduct problems (such as fre sein, animal abuse, destruction of propery) K sect ‘Peers of adults have expressed concern about the student's potential for x violence History of drug or alcohol use or abuse Prior juvenile justice involvement Se “Writings suggest violence or interest in violence [Social ‘Student is alienated from the ‘normative’ peer group ‘Student affiliates with antisocial peers Student has dficaty with social sis and peer relations 4 (Other: cademi ‘Student has poor school achievement Shident is frequently absent from school XX "There has been a recent negative wrend in school achievement or truancy Tistory includes disruptive behavior in the classroom on History includes numerous suspensions [Emotional Student has difficulty controlling impulses Student has had recent emotional outbursts ‘Student has had recent episodes of unwarranted anger ‘Student expresses hopelessness or heightened anxiety Stadent is overly senltve to erieism ie istry of emotional problems ora diagnosis of @ mental disorder Cale, si ‘Known diffcaly coping wih sessfol event) 4 or, don re Other Tis oF | ironment ‘Student has experienced increased stress al home or school Student report a poor oF negative elatonship wih parenis a pw ‘Student has experienced increased conflict with parents ‘Student lacks supervision outside of school ‘Student is exposed to violence at home or in neighborhood x “Sudent is frequently exposed to violence in the medial video games x ending ers change in creumstances " % Oe Habis Tina st fons = Dok med 52ers - fo heme feamdly Ph Coe dn