STRICTLY PUPIL SUBJECT TO EXCLUSION   Ref. No.         /
CONFIDENTIAL For Office Use
Personal details -
School   Location   NCYG  
Full name of pupil   Date of birth  
CoP Level 1 Ethnicity 2 Unique pupil number 3
Home address  
Home telephone number   Looked after
status		 4
Parents/Guardians Names  
Parents address if different to home address  
Exclusion type and period -
Permanent 5.1 From: 5.2
Fixed Term 6.1 From: 6.2 To: 6.3 Days: 6.4
Reason for exclusion -
Description: 7
Further details if appropriate:                    
 
Administration:
Date Governors informed:                      
Date L.E.A. informed:                      
Date parents informed - Verbally:       In writing:          
Have the parent(s) been informed of their right to submit representations to (i) the Governors, and (ii) the Local Education Authority? Yes / No
  Signed                  Date         
  Headteacher  
                             
When completed please return to -
Sally Moy, Pupil Access & Support Services, Boardman House, Redwell Street, Norwich  NR2 4SL
Notes to help completion of the Pupil Subject to Exclusion form
1 Please enter the Code of Practice level the pupil is currently on by using one of the following codes:
N No special provision
A School Action
P School Action Plus
Q School Action Plus and Assessment
S Statemented
2 Select one ethnic description from the list below and enter the number or description into the relevant box (2) on the form.
1 White        
2 Black - African    
3 Black - Caribbean    
4 Black - Other (specify)  
5 Indian        
6 Pakistani      
7 Bangladeshi      
8 Chinese      
9 Any other ethnic group (specify)
10 Unclassified      
3 Enter the unique pupil number in the box (3) on the form.
4 Enter the current looked after status if appropriate in box (4) using the codes below:
C In Care
A Care Authority
S In Care at Current School
5.x For a permanent exclusion tick the box (5.1) and enter the date of the first day (5.2) the pupil is not in school.
6.x For a fixed term exclusion tick the box (6.1), enter the date of the first (6.2) and the last (6.3) day the pupil is not in school and the total number of school days of the exclusion (6.4).
7 Enter one description from the list below which best describes the most important reason for the exclusion into box (6).
Physical assault against a pupil      
Physical assault against an adult      
Verbal abuse/threatening behaviour against a pupil  
Verbal abuse/threatening behaviour against an adult
Bullying            
Racist abuse            
Sexual misconduct          
Drug and alcohol related        
Damage            
Theft              
Persistent disruptive behaviour      
Other