‘Administrator (Discipline AP o Principal) + Pacons, time and circumstances allow + Seno! Counesior + Case Worker slusiestet or ward of the Court 4+ School Resource Offs, by consutaton parents or Case Worker ae unable to atend, + Educators or other people wo know the student ‘seek veral input tthe protec questions. "studenis, Use leacherstat questionnaire + Campus Monier, if possible. needed. + Deputy Fie Marshal, by cansutaton ‘Many cases can be managed though a Level 1 Scceening wih appropiate Interventions. The screening usuly takes from 20 o 45 minutes and s a way of documenting concerns and management statgies. Its also a way to dotomine ‘tthe sa need to request a Level 2 consultation staf that specializes i fr-behaor investigation (top 6), If {ontulatin s needed egarcing the Level tor Level 2 process, please call Courtenay McCarty a Student Satvces or by eal609) 510-0263, LEVEL 1 SCREENING AFTER CALLING LOCAL FIRE DEPARTMENT FOR FIRE SUPPRESSION OR INVESTIGATION, DO NOT DISTURB OR CLEAN UP FIRE DAMAGE UNTIL DIRECTED BY FIRE DEPARTMENT PERSONNEL, C1 Inecessary, take appropriate precautions such as detaining the student and restricting access to ‘coats, backpacks, lockers, ete i IMMINENT DANGER EXISTS CALL LAW ENFORCEMENT, LEVEL OFFICE, ‘AND FOLLOW THE DISTRICT SAFETY GUIDELINES. 1 Notication to parent/guardian of dented targeted studei(s) a outned in Level 1 Student Treat Assosemont Protos Wy {Gl ne parent gueraan has been noted thatthe Level screening is being done, The paren’ guardian has net been noi of his mating because arent proved input through verbal contac or team partcipaton, Use Laval qasstons aa a baal fv discussion ‘SCHOOL: __Chavez Elementary SCHOOL PHONE ft: 509-900-2571 TODAY'S DATE: neno01s PanSSins——Reseesarzr201sADMINISTRATOR / CASE MANAGER: __Olna Cot DATE OF INCIDENT: 2192016. [STUDENT NAME, TUDENT & OB: 051032008 __AGE:7_ GRADE: 2 PARENTNAME(S):__/ }__ Hone #: 974-720-5481 DX copy oF pisTRicT INCIDENT REPORT IS ATTACHED. Fire Departent noted: [} Yes (JN FireDaparment examined te scene: Yes {2 No Law Enforcement (SRO) notified: []¥es [No DHS Caseworker notified: [] Yes [No BINA Probation Officer Notified: (]Yes []No BE] NIA Other Notification: Was student cited or roferred by the SRO/ Fire Department investigation? [No [] Yee (ifstudont is eted, consult with the fire marshal. Fire-behavior screening is usualy delayed unl ordered by Juvonile Deparment. Fire marshal contact for fr eafety education fr family may aso be avaliable) Student referred with parentiguardian support to Local Fie Department for uvene with Fire-beha 3 Screening. Date: Local Fre Department (essential) | —— ProbationiParote Officer, a Students private therapist (recommended) HS Case Worker, I avaiable Each question a prompt for exploration of the nature of ta fesoting incident. Please noe concems by each tern. Review the questions below as an outline for a guided conversation investigating the nature ofthe firesetting Incident in question, Sources of information may include parent, student, staff, Fire Department Representative and SRO. Because fre setting may be a cima, check with SRO and Deputy Fire Marshal if thare are any limits on information gathering DESCRIBE INCIDENTICONCERN | Who, what wh fen, Pow While incase, was trying to stata fre using pencis When that id not work, he ried! etonin= ~ using slesors fo create.a spare Upon speaiing with Je yther, she reported that nthe past ‘srother has slarted a firein her horenthe trashoan ;porledhe knows how to start a fra Because his mather showed hn how ta before E INDICATORS OF STUDENT INTENT (Full assessment of intent exceeds school responsibility) FREES Reteosscara01s‘Ls there a known history of previous firesatting behavior? [No 3 Yes, if'yes describe: Started are nthe home (vashcan Note: previous fresating behavior fay suggest a move serious concer, Consider Supervision Strategies (page 11-12): 3, 10, 15-16, 27, 22, 33, 56 2.Have any ofthe individuals involved inthe firesetting incident been proviously censured, disciplined, o placed on a behaviorleafety plan for freselting behavior? EINo “Lives, ityee describe: — — sponse fo censure may suggest a mare serious concem, Consider ‘Supervision Strategies (page 11-12): 3, 10, 16-16, 27, 32, 33, 86. 3.Student uses media (internottolovisionfiteratureimovlesvideo gamesiete) to access information about Sartng fos andlor making explosive devices? TINo” C1 Yes, iyes describe Unknown . ‘Noi: media usa regarding froceing suggecis the possbliy of pramadtaton as well asa preoccupation wit freseting. Consider Supervision Strategies (page 11-12): 1-8, 22 4.Student has made t known to staf, students or public-at4arge hisiher desire or intention to burn down the ‘school or set fres(verbalonline postingfte). EGNo "Lies, tyes describe ‘Noe: studons who are verbazng ter ntent to set es are mare Rely fo acl on that nvent than Sudan who do not verbalae intent. Consider Supervision Strategies (page 11-12) 1-8, 3, 10, 15-16, 27 22. 32,23, 56 ‘.Does student express or evidence fascination with fie andior fire related activities or personnel. BANo" “C1 Yes, tyes describ ‘Hota student who exidonos ierestin Wessling selves and tre personnel may Be more IRay engage the seting atv, ®.Describe property damaged, ts proximity to people and its estimated value No property damage at schooi. Fie at home-unknown extent of damage ‘ole: misuse of fre as a means of causing propery damage may sugges! criminal inking. Fvevating hat put ‘others at isk of physial injury suggests a lack of concern for ethers onthe pat ofthe eset. or fey anicipsting outcome ofthe resting. Misuse of ie an occupied structure may suggest tent lo eause harm to athrs andlor profound ack of foresight ‘.Descrbe inury to studont and others caused by the fire,___none_ a5 a means of causing Bodly unto se or ohare sugaaets a patologk‘Aso, Siar eral or Sule RIK Assessment andlor Shadent Thréak Assessment Team, 8.Firesetting appears ritualistic or follows a pattern, BaNo Lee, lf yes describe: ‘Wate he prescrce of tualin a ieseting nadent may dnl promediaion Consider Supervision Strategies (page 11-12): 3, 10, 15-18, 27, 22, 32, 23, 56, 89 9, Object that was set on fio is symbolle-balonging fo anther student orto a staff member. GaN) es, tyes describe _ Fite teesting to a yoke one ay sggast hal ie Sent may Deus ro stig commune fenotonalpsychologicl turmoil, Consider Supervision Strategies (page 11-12) 3, 10, 15-16, 27, 22, 32, 33 56,50 | 40, oid tt arnt or others vole astrong visceral respons ering the eseing eden? | Bano. T1Yes, yas describe: ‘Hota song vscoal response suggests tal ndvidoas have a saviovs concar tatis afc to vebalae, Careful review ofthe incsdantiseconmended ACCESS TO FIRE MAKING RESOURCES 41. How did student tart the te? Student was unable to startit, but was attempting to._ ‘Wate immediate resources at hand? Brought resources a schoal? Consider Supervision Srafegies (page 11-12): 33, 42, oes the student or family smoke? Pio” Li Yes. ityes deseribe ccossibiity of firesetting materials: ___unkwn,_ Aes sadets whose fal members emake general have greaior access fo reseing matrals and Knowledge with regard tohow to use them, Consider Supervision Strategies (page 11-12): 33 43, Whore dd the student get the frestting materials? Doser. classroom materials Noto: lnoaTedge where te frosting malaiais ware Garered is cilcal with regard tthe development of ‘he saftysupanision plan, Consider Supervision Strategies (page 11-12): 33 14. Firesotting involved use of accelerants BE'No. Les, if yes describe: a Nola HS GTSSSSRTaTIS SURIGUD aka Gagrea af Panning and tanto eaute Game was pose (Consider Supervision Strategies (page 11-12): 33 45. Was fuol added to keep the fire going? 1] No Ces, if yes describe ae 6Nia: mediate resources at hand? Brough resouroes fo schoo? Consider Supervision Strategies (30 | 11-12):33, 16, Did the student attempt to put the re out, callforhelp or leave the fire burning? Describe behavior N ‘cies Aap suppress Wa or cal lor hap may indicate far or remo FIRESETTING OPPORTUNITY 7 Tasaribe the ccamslaneas ofthe fre even. Was the sudant acing alone? Was the siden served by | 7'ifs0, how? Were peers acively svolved-asiting in some way? Tdiass and was rubbing pencis together to start fre, when that didnt wore atempted to start te ising sls, Betas he tas Matory of esa air (stoped by mom), ter tay Beek of future evens. Other students nthe elaceroom ais se batlempting ta stat the fre and reported tothe teacher. ‘ole Understanding the souroe ovation wil guide te cupervkion needed. (Eg, inpusive Sudanis may sed diferent supervision planning than targeted plan ul students] __ OTHER INFORMATION Sone ARES vena womens48, Spocial Education? CINo Elves Past/Present Inforation _ 19, Suleidal ideation? BINo [Yes Past/Present [| Refer: Sulelde Risk Assessment Information 20, Targot threatof violence? (No C]Yes Past/Present Refer: Student Throat Assessment Information 24, Concorning Sexual Behavior? [No [| Yes Past/Present Refer: Sexual Incident Response Information: Has a SIRG in lace curently ‘other concerns (Stability of care, exposure to abuselviolence, supervision, fre-bahavior ole modeling, Imputsivity, socialization, aleohoitdrugs, role models, school achievement, animal harm) Iimpustlve, At me aggressive, ADD, "ability to comprehend impact of histher action Student thinks was ny. i. Other Information | Summarize any other information considered by the team, Include information! recommendations from other sources (DHS, probation/parole, therapist, etc.)‘Ofpetny omske fie Acces retaking Stee Firesetting Incidents occur at the intersection of Opportunity, Materials and Intent. In supervision planning, one should be mindful of the degree to which our strategies ‘Access and Opportunity, and consider the nature ofthe student's Intent. Describe existing ‘approaches that may inhibit each ofthe following. Basic approaches include education, relationship building, supervision, accountability and collaborative problom solving. For ach of tho following arose, identify helpful family, student, echool and community and professional resources and strengths, “ype ofinswrance Existing supports that help discourage intent to start a firo: (Example: Postve relations, ee safety education, mental health series) Existing supports that inhibit access to fire making materials: (Example: supervision, securing lighters and supplies, checking ossessionsfbackpack) Existing locations that inhibit opportunities to starta fire, (mark all that appl D Transitonsiningup [Classroom [J Recess/tunchiAssembies Deus athreom Waking Home Bother Reon 8272015.RECOMMENDED INTERVENTIONS (CHECK [X] IF IMPLEMENTED): Individual Options: 4. Bl itended vietn(e) warned — parertlguarslan nlifed (ee Level 1 Student Thret Assessment Protocol) 2 [Protective responce inated by Safety and Risk Management Departrnent a Inciviual aeoountabilyeuppor plan (expectations, problem solving resources, supervision pan, review dale) suicide assossrentinttated on [use DistetSuilde Proteca}) ae 5. [Noha contract 6. Ei Treat investigation initiated on, {use Distct Threat Assessment Protoca!) ae CSemal incon nunntigaton ited on (use Dishiet Sewal Incident Prtoest) co 8, CJ Student wit seif manage: Deserbe: 8, Cotter. School Options: 10: CT Reeate of ntormaton wit oe re dparnent. Hn whyNo ee slat 11, Ey Release of infomation wih cher suppadive communty service providers 2 E Bus suporison (Speaty I Safely Plan) Xi 14 Student escorted fom Bus to schoo fe, and from classroom to school bus Student escorted to and rm school fice by adult, spect. ine-of-sight supervision (Zone) 18. FAams-each supervision (One-on-one) ‘Supervised hinchPbreaksirecesslassembly 18, B Special lasroom seating assignment (o increase supenision) 19. [)Noafer-school actives. 20, C] Supervead after-school actvtes (spect in Safety Plan) 21. Cl Academic acti resticions BN aczee ener svar ins ere 2 Behaviora expectations! behavior contract signed by student and parent, Date (pacatons, problem saving resources, supervision plan, Indicators of progress, review date) Review educational plan 25 E)Roterto IEP Tear © Reason 26, Bl Soca services (School Social Worker, hdvidualzed Edveation Plan, School Counselor) 27.) Educational nteview wth SRO andlor Fle Dept. Personnel 22, [Travel earg and ne aocourtabilty 2, 5) Social exits bulding programs 120, B Inereace supervision in fotouinggatngs in the following ways: osifieaions of daly schedule L] lato arival/earydsmiscal staff on need to-know asl, Speci staff: supervisory staff [-]Teacher only {Teacher and LA’s only []SRO fi Office sttt ‘Staff member esponelble for alerting staff and teacher +33, E] Random Cheek of backpack, lockar, pocket, purse, el. byr ladmiigrator [1 Schoo! Counselor (1 offee staff C1 other, 34, C] Assign Wentieg sao bul tusting elatonship trough check Or SnRTBE [Acminietater 1 Mentor Dd Scboel Counsslo [_] School Resource car Bd Teacher [Other __ 236, Bf Provide maans by which student may safely reper and dscuss concerning thoughts or intentions and esse rope erento 2a, [falta cho! engage he stint nd poate relationship and behav. Es FREESE ess wazn1s "438. D tently and futher develop acts, relationship or expaionces of val that inhib possibilty of ating out. “Continue to elatonship bul and cotaborate with parent 38, Schoo! Counselor: _Coninue to retatonship buld and colaborate with pent 40, Clothes (woTe: students on P1504 plan any change In placement or Spocal Ed eervices must be done though "Special Education Team processor S04 fam process) 44, CJ Refaralo appropriate school tam to conser atemaive placement 42, E] Homa aupershion pending futher information gathering 45, Cl ineoasod supervision nthe folowing settings 4% El Reteral to Abpropist Special €3, Team lo coneideraaAtonal Spockl Education Assessment or Behavior "Foam Refer (NOTE: Must be done through Specal Education Team Process.) Parent / Family / Home Options: 45, [1 Consul with fee dept. persoana for home fre safely Assessment 48. El Salty proathome (emote alas, secure Irion and acoelerents, el) (Guidelines for Garogivers of Juvenile Frossters Handout (avalible cn U-Drive with Juv. Fre Behewor Protocal) 47, &| ParonuGuardian informed of egal responsibilty via Parent Responsibility Handbook (availabe U-Dive) 48. ed Increase supervision 4 Bi Une-otsight supervision Recommended 50. BJ Reviow and pursue cis andor mental heath services 51, [No aocess to internet 52. [] Superised access to ntemet 53 ClPosine Home Actvites Community Options: Referal io YST Retoral OHS. Date: Recent fr-bohavior vent Refral fo local fire Department for fire-behavor screening isa priority HAS ure POI iz i Fie selety class reconmenced ty local fe deparimont Student wil sefenanage. Describe: Monta neath evaluation Inidual manta heath counselor Family erapy Anger management programs ‘Aepbeiéng evaluation Pening posers fenton programs [D Cecrainate wit Probation Parola Oficor 7 F Coordnate wit Mental Heath Counsaior ceoranate with DHS worker th based community programs. sseqsaeseessse sae RRSSOE — Rnveedezra0 12ria that may st in future supervisi [D compiate Juvenile with Fire Sereening by fre department [F] Complete fre eafety education recommended by is departmont [D]Stidente parents responsive mn completing recommendations put oh by communty service provider [Bi Student cemenetates eomplance wth ncdent related expactatons 2s evidenced by. ‘Shdene recognizes across Setings the mpactof is behavior on hers [Gi student’ relationship with identi suppor staf has imoroved sce comortae capaci sak hp wen dean wih plane Ly cormamty senice prvr report ogress, Spety sea of sono: feam agree Review: ‘= BeinistratorToam wil review the status ofthis plan and revise as needed on: ISL AG Geer ‘After local fre department compiles the Juvenile wh Fre Screening, the team wil revew recommendstons. CONSIDER REQUESTING A LEVEL 2 CONSULTATION, “The Sita Team may request a Level 2 consulation fam the County Jwenle Fosetor intervention Network Team fora youth with event resetting behavior and signfeant ck concerns, Sudents percaved reseting infant, evel ‘of planning ad history are important risk consideration, “Team review may include consderation of school and home supervision needs, intervention options, commniy ‘esources and releral upper. The Team meetsn a schodued basis. The Site Team sdmnistator el artetpate Inthe case roview, “To request a Level 2 consultation, complete step Sn the Level 1 Protocol. Contac Dispatch at (302) 975-7658 or (503) 10-8924 to request a Level. (Once a students tafe, case management vill be done from the school st by the bulking administrator and Feviewed ona schedule determined al the ime of he assessment or as needed If station escalaies. A Level2 {olow-p wl be determine atthe time of cancutaton, The stent may be reviewed again by te Level 2 Team at tha rogues ofthe Ste Team. See Step 5 for Level 2 Firesetting Incident Response referral process. RIEGSESEE rss rans 13ee 4While awaiting the Level 2 response, use the student supervision plan (Step 4) to manage the ‘situation and document interim stens taken by Site Taam. ONNEEDEDIFO ISTANGE WITH At 11s student adjudicated? Ces [No Ityee Name of Probation Officer Phone 2. Award of the court or other supervision? []¥es [No Htyes, name of caseworker Phone 3. Name of Deputy Fire Marshal contacted: 4, Did student receive criminal charges for the firesetting? []¥es [No Ityes, ist charges: 5. Other agencles or individuals involved with the student (therapists, doctors, etc.) that have or will be contacted by a Level 1 Team member for recommendations. yes, is there signed consents for exchange of information? C1] Yes. [-] No Ifyes, please list agencies and indviduals: Phone Prove: Prove: 6, Special Ed. Or 604 Involvement, disability codes and current placement? [] Yes CINo Ifyes, details: 5, Is student in setf- contained classroom? C] Yes [No 6. Was parent or guardian present or provided input for Level 1 screening? [] Yes CJNo 7. Parent or guardian provided information int present? []Yes L]No 8, Summarize significant risk factors (perceived intent, level of planning). FREESE Reveod wana| | eee » | |LEVEL 1 OUTCOME. (To be completed at the end of the Level 1 Investigation) Disposition Date Responsible Party {__] Gather More Information Dismiss Develop Supervision Plan Refer to Level 2, ifneeded Share Level 1 wiFire Department _ Parent/Student Referred to Local Fire Department for screening Release/Notification/Consultation Date Responsible Party DHS Case Worker, if available _ Fire Dept /Deputy Fire Marshal |__| Private Therapist [__] Probation/Parole Officer, if available Notes: Parfcjpant Signatures: = | ~ 2ftalic Adniinistrator, Plan Supervisor ‘Date Parent, if participated Date - 14} lo _ Setigol Counselst on ‘Other Zaha WY Ib Ste Bernvior Speiaisy m= Othe aie ‘Other: Date ‘Other: ~ Date Others os Other: co Sane Revises 7‘Beicpadbwhior acer MSW, LES isn Kone, PRO, al Sb Katey Pbie Sten, oy Cha, Of af Sala Fe ‘nna st sren Sea ron Coun Shr Oe, ey Kapt md eta ConadFare ion Fac ag ‘esp Spec OS song tur tomato: area, Star Rear Soa tet Tea cect hesponn ynr ‘ry ake ata Dalia ee Sey Satan abe ean ser ead at | oHandat of hese Ch and Tau Sat, Demme Pare, sasee an ate re Paeina Bea | RNa eveatecraois | 18‘SALEM-KEIZER PUBLIC SCHOOL DISTRICT 24J — ‘CONFIDENTIAL INCIDENT REPORT FORM meat “nis apoio be use for oping a spect staf ander stadt inedont ———— Ee School or Location: _Chver Elementary Date of neldent 219/16 [ Student Discipine incident Tis scton shoul bo corpo byte SchoalDepariant.CheskiF appropiate) Name ‘Student Number: [Physica ace 00 Reciam on Alcohol & other Droge —Dlebbuton 0) Aggressive Benavior (00 Irsubordnale Behavior 60s) Fireseting 700) tiveat sce) Weapons 605). Dcompute Networks & intomet 23) [F)Harassient, intimidation, Buying 500) (“] Looe Ake Weapons ean (] Property Damage & The 725) GiSoaial Harassment 06) Alcohol & Other Drugs soy} Otver. [Major incident Category Tis scion sion conpltd byte Cathet Lvl Cc. CheekW appropiate] C)uscing Lockdown Drrrerpiesion Studertat rary Discme Treat Cliararaoue substance Leak’spa } Threat. StudeniAdut us Accisent Jess of PowerWater VandatemiProparty Loss {Ei Accidents (other than bus) Gisovere waather Ober: Gicammunicabe Disease ‘Summary of incident: Describe incident in one paragraph. Inde name of individ vole grade of student and lassicaton of empioyeo() ‘Stunt attempted to start a fre in classroom with pencis and metal scissors, When parent was contacted she sid that be had stated a fre inte home in a garbage can Dist safely department recommended a re sting potocl fr Preventative massures. Disposition of incident: ] Patents Noted Cisuspended__ Days pote Noted In Sohal /Appcopsiate District Offces Notified Out Schoo! Under invesstion CD Roterred to Diversion (D Suspended Pending Investigation (D)Suspendes Pending Expulsion Hering (Bi Next Steps: Level Fie setting protocol, Blotier Explain) zune Date ‘Gpovatons Decor Review fo Expulsion Bae PLEASE NOTE: This report may become pblisinermaton FScootoepaamentta Cane Lvl ie sea arnetaton 4 Le oteteStprrarcts Ose Re Msvgensrtand ove a ‘ecpine Sorcer apap