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Run: School Behavioral Threat Assessment Screening and Case Form

School Behavioral Threat Assessment Screening and Case Form documents the initial screen, full-team assessment, management plan, and follow-up for a student ...

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Submission Notice and Consent

Submission Type (required)

Your Role (required)

Acknowledgment of PII and case handling (required)

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.

Yes No N/A

Is there an immediate threat to life or imminent violence risk? (required)

If yes, activate emergency response and district crisis procedures immediately.

Student and Case Identification

Student Full Name (required)

Student ID

Date of Birth

Collect only if needed to distinguish students with similar names.

School Name (required)

Grade Level (required)

Case Opened Date (required)

Case Reference Number

Initial Screening and Referral Details

Referral Source (required)

Date Reported (required)

Brief Summary of Concern (required)

Describe the observable behavior, statement, or event using objective facts.

Type of Concern (required)

Is a specific target identified? (required)

Target Details

Enter only the minimum necessary information about the target.

Screening Disposition (required)

Behavioral Indicators and Context

Recent Changes in Behavior

Observed Warning Signs

Known Access to Weapons or Means (required)

Access Details

Document only the minimum necessary details for safety planning.

Recent Stressors or Triggers

Protective Factors

Full-Team Assessment

Team Review Date (required)

Team Members Present (required)

Information Sources Reviewed (required)

Team Risk Level (required)

Rationale for Risk Level (required)

Summarize the facts, not opinions, that support the team’s determination.

Law Enforcement Notification Needed? (required)

Parent/Guardian Notification Needed? (required)

Management Plan and Interventions

Intervention Categories (required)

Safety Plan Summary

Include supervision, restricted access, and immediate response steps.

Counseling or Support Referral

Schedule or Setting Change Details

Monitoring Frequency (required)

Responsible Staff (required)

Next Review Date (required)

Notifications, Documentation, and Audit Trail

Notification Log (required)

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 (required)

Select the current status after review.

Closure Criteria Met?

Follow-Up Actions Completed

Team Lead Signature (required)

Team Lead Name (required)

Sign-Off Date (required)

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Email (required)

Your name (optional)

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