School Behavioral Threat Assessment Screening and Case Form

Documents the initial screening, full-team assessment, management plan, and follow-up actions for a student behavioral threat case under a school threat assessment model.

Submission Notice and Consent

• Submission Type
• Your Role
• Acknowledgment of PII and case handling
  I understand this form collects PII needed for school safety case management, may be shared with the threat assessment team on a need-to-know basis, and will be retained in the case record for audit trail purposes.
• Is there an immediate threat to life or imminent violence risk?
  If yes, activate emergency response and district crisis procedures immediately.

Student and Case Identification

• Student Full Name
• Student ID
• Date of Birth
  Collect only if needed to distinguish students with similar names.
• School Name
• Grade Level
• Case Opened Date
• Case Reference Number

Initial Screening and Referral Details

• Referral Source
• Date Reported
• Brief Summary of Concern
  Describe the observable behavior, statement, or event using objective facts.
• Type of Concern
• Is a specific target identified?
• Target Details
  Enter only the minimum necessary information about the target.
• Screening Disposition

Behavioral Indicators and Context

• Recent Changes in Behavior
• Observed Warning Signs
• Known Access to Weapons or Means
• Access Details
  Document only the minimum necessary details for safety planning.
• Recent Stressors or Triggers
• Protective Factors

Full-Team Assessment

• Team Review Date
• Team Members Present
• Information Sources Reviewed
• Team Risk Level
• Rationale for Risk Level
  Summarize the facts, not opinions, that support the team’s determination.
• Law Enforcement Notification Needed?
• Parent/Guardian Notification Needed?

Management Plan and Interventions

• Intervention Categories
• Safety Plan Summary
  Include supervision, restricted access, and immediate response steps.
• Counseling or Support Referral
• Schedule or Setting Change Details
• Monitoring Frequency
• Responsible Staff
• Next Review Date

Notifications, Documentation, and Audit Trail

• Notification Log
• Records Retention Note
  Store the case record according to district policy, applicable state requirements, and the school’s audit trail procedures.
• Submission Timestamp

Follow-Up, Closure, and Sign-Off

• Case Status
  Select the current status after review.
• Closure Criteria Met?
• Follow-Up Actions Completed
• Team Lead Signature
• Team Lead Name
• Sign-Off Date