COMPLAINT - SCHOOL TRUANCY/DEFIANCE FAMILY WITH SERVICE NEEDS STATE OF CONNECTICUT JD-JM-119 Rev. 4-12 SUPERIOR COURT C.G.S. §§ 46b-120, 149, 10-198a, 10-200 JUVENILE MATTERS www.jud.ct.gov Address of Court Docket number Name of child Address of child Child's race American Indian/Alaskan Native Asian/Pacific Islander Grade Sex Date of birth Indian tribe/reservation, if any Hispanic Black Unknown Name of mother Yes No Address of father Name of guardian, if any Other Address of mother Name of father White Address of guardian Mother's home telephone Mother's work telephone Name of complainant Father's home telephone Father's work telephone Guardian's home telephone Guardian's work telephone Telephone Fax number Address of complainant Name of school and contact person at school A family with service needs complaint may be filed only after the school has exhausted all available options to rectify the problem. A complaint may be found insufficient if it does not include the following as required by state law including, but not limited to, Section 10-198a of the Connecticut General Statutes: ("X" box if action as been taken) A meeting was held with the parent of the truant child and appropriate school personnel reviewed and evaluated the reasons for the child being truant. The meeting was held not later than 10 school days after the child's 4th unexcused absence in a month or the 10th unexcused absence in a school year. Coordination of services and referrals for the child were made to community agencies providing child and family services. Every year, at the beginning of the school year and upon any enrollment during the school year, the parent was informed in writing of his or her obligations or the obligations of any other person having control of the child under Section 10-184 of the Connecticut General Statutes. School personnel made reasonable efforts to notify the parent or other person having control of the child by telephone whenever the child failed to report to school on a regularly scheduled school day and no indication was received by school personnel that the child's parent or other person having control of the child was aware of the pupil's absence. If records are incomplete or do not exist please attach an explanation for the Court. Type of Referral The family is a family with service needs because it includes a child who is (place an "x" in the appropriate box or boxes): Truant (Four (4) unexcused absences in one month or Ten (10) unexcused absences in a school year) Habitually Truant (Twenty (20) unexcused absences in a school year) Defiant (Continuously and overtly defiant of school rules and regulations) (Page 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com Attendance List specific dates of unexcused absences in the space below. Do not just reference the included attendance report in this section. Behavior If this referral is based on the child's in-school conduct rather than truancy, provide documentation that the child has been continuously and overtly defiant of school rules and regulations. There must be a pattern of defiance over a time. A single incident is not sufficient to establish that a child is defiant of school rules. (List all dates and description of behavior) List date(s) of meeting(s) with parent(s): Parent or guardian did not attend meeting(s) on attempting to solve the truancy problem. or otherwise did not cooperate with the school in Community Services attempted on: Has the parent or guardian been notified of the filing of this complaint? Signed (Superintendent of School, only) JD-JM-119 Rev. 4-12 Yes Print or type name of person signing No Date signed (Page 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com