PEX Form

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School's Locality

North

South

East/Central

Referrer details

Name of staff completing

Direct phone number (if available)

School point of contact email

Please provide the date of Permanent Exclusion

Note that the official date of permanent exclusion is the date the LA confirms receipt this form.

Date of Permanent Exclusion

Date of PEX Hearing (if known)

Date of Exclusion Meeting

Child's details

Forename

Surname

DOB

Address

UPN

Pupil Gender

Female

Male

Non-binary

I prefer not to say

Other (please specify):

This is required

Does the child or family require an interpreter?

Child does

Family does

Religious affiliation

Ch - Christian

Hi - Hindu

Je - Jewish

Mu - Muslim

No - No Religion

Ot - Other

Ra - Rastafarian

Si - Sikh

Un - Unclassified

Parent/Carer 1 details

Full Name of Parent/Carer 1

Direct phone number (if available)

Address

Relation to Pupil

Parent/Carer 2 details

Full Name of Parent/Carer 2

Direct phone number (if available)

Address

Relation to Pupil

Does any other person have parental responsibility?

Yes

If yes, please give details:

This is required

Family Context, e.g. Parents separated or together, siblings, wider support system

Please give more detail/information regarding the incident and behaviour leading to the permanent exclusion: It is essential this area is completed in detail

Has the pupil been permanently excluded before?

Yes

If Yes, please name previous excluding school:

This is required

Please upload any Support plans or IEPs for this pupil

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Maximum of 10 files, up to 50 MB each

Maximum number of files reached

Please remove some files before adding more

Have you had an inclusion support meeting or Inclusion surgery slot for this pupil?

Yes

If yes, please confirm the date and any actions from this:

This is required

Have you received resources from IncludED for this child previously? (For example: funding, a mentoring package)

Provide details of this in the comment box and impact on educational outcomes.

Yes

Comment:

This is required

Level of SEND (Special Educational Needs and Disabilities) -

If child has an EHCP - you must follow SEND Code of Practice and DfE school suspension and exclusion guidance and consider an emergency annual review before deciding on Permanent Exclusion.

No SEND

Monitoring (N)

SEND support (K)

ECHNA

EHCP

Please add details as to progress around stage (e.g, ECHNA submission date, whether overdue, Panel 1 or 2, Intention to submit ECHNA)

This is required

If you answered YES to having an EHCP, you MUST upload it here:

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Maximum of 10 files, up to 50 MB each

Maximum number of files reached

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Are you are receiving Top Up funding from the LA for this student?

Yes

If so, please record the banding and the amount:

This is required

Has the pupil been assessed for ADHD / ASD / Dyslexia / Speech and Language difficulties?

ADHD

ASD

Dyslexia

SALT

Dyspraxia

ODD

Other (please specify):

This is required

Comment:

This is required

Does the pupil have an official diagnosis?

Is the pupil in receipt of additional support?

Yes

If YES, please specify what support they receive:

This is required

Safeguarding information - Please provide dates to assist understanding of historical and or current concerns.

Adverse Childhood Experiences that may not have met a threshold for social care intervention. Please outline.

Contextual Safeguarding concerns - Please outline.

Current social care threshold (Early Help, CIN, CP,CIC) - reason for involvement?

Historical social care thresholds (Early Help, CIN, CP, CIC) - when? reason for involvement?

You MUST upload a PDF of CPOMS or other safeguarding record. This is essential for 6th day provision.

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Maximum of 10 files, up to 50 MB each

Maximum number of files reached

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Is the pupil on the Child Protection Register or are they a Child in Need?

CIN

If CP or CIN, please supply additional information:

This is required

Has the Social Worker been informed of the PEX? (if appropriate)

Please note this is a requirement in the DfE exclusion guidance.

Yes

Is the pupil at risk of Child Sexual Exploitation?

Yes

If YES, please supply additional information:

This is required

Is the pupil subject to a CSE or Domestic Abuse MARAC?

Yes

If YES, please supply additional information:

This is required

Is this pupil looked after by the Local Authority (Are they a Child in Care)?

CIC (Current child in care)

PLAC (previously looked after child)

SGO (Special Guardianship Order)

If YES, please give more information:

This is required

Has the virtual school been informed of the PEX? (if appropriate)

Please note this is a requirement from the DfE exclusion guidance.

Yes

Which other agencies has the school involved in managing the pupil’s behaviour? (Current and historical)

Full contact details are essential

Education Welfare Service

Education Psychology Bristol (TWS)

Education Psychology - independent / private

Social Care / Early Help

Youth Offending Team (YOT)

Hope Virtual School for Children in Care

Child & Adolescent Mental Health Service (CAMHS)

Alternative Learning Provision (ALP/AP)

Behaviour or Learning Improvement

Speech & Language Therapy (SALT)

Safer Connections/Harm Outside the Home

Other Agencies (please specify)

Does the pupil receive Free School Meals?

Yes

Does the school receive Pupil Premium for the pupil?

Yes

Are there Health & Safety concerns?

Truancy/Absconing

Fighting

Damage to school

Self-harm

Other (please specify):

This is required

If YES, please provide details:

This is required

You MUST upload an up-to-date Contextual Risk Assessment. This is essential for 6th day provision.

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or click to browse your files

Maximum of 10 files, up to 50 MB each

Maximum number of files reached

Please remove some files before adding more

Are there any Mental/Emotional Health needs?

Yes

If YES, please provide details:

This is required

Have you previously contacted parent(s)/carer(s) about the pupil’s behaviour?

Yes

If YES, please provide details of how parents have been involved:

This is required

Current education/targets

English

Maths

Science

ICT

Other

Any other assessment information:

This is required

Please provide the pupil's reading age and date when assessed.

Please specify which test was used.

Curriculum: Pupils in Y10 & 11 Only - Exam entries

Exam 1

Exam 2

Exam 3

Exam 4

Exam 5

Exam 6

Exam 7

Exam 8

Exam 9

Exam 10

Does the pupil require additional exam support and have arrangements been made:

This is required

Attendance

% attendance over the current term

% attendance this academic year:

% attendance last academic year

Where there have been attendance concerns, how have these been addressed by the school?

This is required

Please attach an attendance record

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Maximum of 10 files, up to 50 MB each

Maximum number of files reached

Please remove some files before adding more

Previous schools attended & dates

Any other additional, relevant information:

Confirm that you are the Headteacher of the excluding school

Only the headteacher can make the decision to permanently exclude.

Yes, I confirm I am the Headteacher

Signature of Headteacher

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One file allowed, up to 50 MB

Maximum number of files reached

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Date

Date of completion

Page 1

Please chose the setting you are representing

School's Locality

Referrer details

Please provide the date of Permanent Exclusion Note that the official date of permanent exclusion is the date the LA confirms receipt this form.

Date of PEX Hearing (if known)

Child's details

Pupil Gender

Pupil Year Group

Ethnic Origin

First Language

Does the child or family require an interpreter?

Religious affiliation

Parent/Carer 1 details

Parent/Carer 2 details

Does any other person have parental responsibility?

Family Context, e.g. Parents separated or together, siblings, wider support system

Reason for permanent exclusion (Please tick NO MORE THAN 3 boxes)

Please give more detail/information regarding the incident and behaviour leading to the permanent exclusion: It is essential this area is completed in detail

Has the pupil been permanently excluded before?

What has been your graduated response? Please provide details of impact on any educational outcomes in the comment box below.

Please upload any Support plans or IEPs for this pupil

Drag and drop your files here

Maximum number of files reached

Have you had an inclusion support meeting or Inclusion surgery slot for this pupil?

Have you received resources from IncludED for this child previously? (For example: funding, a mentoring package) Provide details of this in the comment box and impact on educational outcomes.

Level of SEND (Special Educational Needs and Disabilities) - If child has an EHCP - you must follow SEND Code of Practice and DfE school suspension and exclusion guidance and consider an emergency annual review before deciding on Permanent Exclusion.

If you answered YES to having an EHCP, you MUST upload it here:

Drag and drop your files here

Maximum number of files reached

Are you are receiving Top Up funding from the LA for this student?

Has the pupil been assessed for ADHD / ASD / Dyslexia / Speech and Language difficulties?

Does the pupil have an official diagnosis?

Is the pupil in receipt of additional support?

Safeguarding information - Please provide dates to assist understanding of historical and or current concerns.

You MUST upload a PDF of CPOMS or other safeguarding record. This is essential for 6th day provision.

Drag and drop your files here

Maximum number of files reached

Is the pupil on the Child Protection Register or are they a Child in Need?

Has the Social Worker been informed of the PEX? (if appropriate) Please note this is a requirement in the DfE exclusion guidance.

Is the pupil at risk of Child Sexual Exploitation?

Is the pupil subject to a CSE or Domestic Abuse MARAC?

Is this pupil looked after by the Local Authority (Are they a Child in Care)?

Has the virtual school been informed of the PEX? (if appropriate) Please note this is a requirement from the DfE exclusion guidance.

Which other agencies has the school involved in managing the pupil’s behaviour? (Current and historical) Full contact details are essential

Does the pupil receive Free School Meals?

Does the school receive Pupil Premium for the pupil?

Are there Health & Safety concerns?

You MUST upload an up-to-date Contextual Risk Assessment. This is essential for 6th day provision.

Drag and drop your files here

Maximum number of files reached

Are there any Mental/Emotional Health needs?

Have you previously contacted parent(s)/carer(s) about the pupil’s behaviour?

Current education/targets

Please provide the pupil's reading age and date when assessed. Please specify which test was used.

Curriculum: Pupils in Y10 & 11 Only - Exam entries

Attendance

Please attach an attendance record

Drag and drop your files here

Maximum number of files reached

Previous schools attended & dates

Any other additional, relevant information:

Confirm that you are the Headteacher of the excluding school Only the headteacher can make the decision to permanently exclude.

Signature of Headteacher

Drag and drop your files here

Maximum number of files reached

Date

Please provide the date of Permanent Exclusion

Note that the official date of permanent exclusion is the date the LA confirms receipt this form.

What has been your graduated response?

Please provide details of impact on any educational outcomes in the comment box below.

Have you received resources from IncludED for this child previously? (For example: funding, a mentoring package)

Provide details of this in the comment box and impact on educational outcomes.

Level of SEND (Special Educational Needs and Disabilities) -

If child has an EHCP - you must follow SEND Code of Practice and DfE school suspension and exclusion guidance and consider an emergency annual review before deciding on Permanent Exclusion.

Has the Social Worker been informed of the PEX? (if appropriate)

Please note this is a requirement in the DfE exclusion guidance.

Has the virtual school been informed of the PEX? (if appropriate)

Please note this is a requirement from the DfE exclusion guidance.

Which other agencies has the school involved in managing the pupil’s behaviour? (Current and historical)

Full contact details are essential

Please provide the pupil's reading age and date when assessed.

Please specify which test was used.

Confirm that you are the Headteacher of the excluding school

Only the headteacher can make the decision to permanently exclude.