Nintex Live Forms

Educational Neglect / Truancy Diversion Referral Form

Date Referred to AIM

School Year

Attendance Intervention Meeting (AIM) date cannot be the same as the Referal date

Date 3-Day Mandatory Parental Notification Letter Sent

Referral Type
*

Referral Date

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Please have all relevant information available to fill out this form in it's entirety prior to starting.

For Which Language?

Please be advised - It is the responsibility of the school to provide interpreter services if needed.

Interpreter needed?

YesNo

Lives With? (select all that apply)

MotherFatherLegal Guardian

Enter complete parent/guardian information.
If parent is deceased, put deceased in first line of Address and City fields, choose Minnesota for State, and enter 00000 as the ZIP Code.
If address is the same as other parent, please put Same as mother or father.

Information for:

MotherFatherLegal Guardian

Name

Home Phone

Cell Phone

Email

Address

City

State

ZIP Code

Information for:

MotherFatherLegal Guardian

Name

Home Phone

Cell Phone

Email

Address

City

State

ZIP Code

Add another parent/guardian

Select all pre-referral efforts taken (at least one) and provide details - required

Communication with Parents

Other Distance learning engagement

Doctor's Note

Meeting with Student

School Consequences

Home Visit

Welfare Check

Other

Doctor note required?

Other concerns:

Is this student being considered for a 15 day drop?

Is this student a transfer from another county?

Please specify the county the student is transferring from:

Have attendance expectations been clearly communicated to the family?

Has student's access to required technology been confirmed?

If unable to reach family, were emergency contacts used?

Primary Language:

Receives Special Educational Services?

Primary Disability

ELL?

Other

Is there an active evaluation in process?

Date Evaluated/Updated

Is there a special education meeting scheduled?

When?

Type of Attendance?

Distance LearningHybridIn-Person

Is the student currently failing any classes?

Which classes?

How is the student doing academically?

Student is credit deficient

Please upload the student's current attendance records. If attendance records are not included, the process will be delayed.

Add Attachment

All meetings will be held in person unless specifically requested below.

In addition to unexcused absences, please add any additional information that prompted you to make the referral.

Name of School

Official and Title

Phone

Address Line 1

Address Line 2

City

State

ZIP code

Email (to receive a confirmation email & schedule the meeting)

If you wish to retain a copy of your referral, please print a copy BEFORE submitting!