LTS | Threat Assessment Anonymous Suggestion Form Communications & Marketing Requests CultivatED Professional Development Legacy Brand Guide Legacy List – Add Listing Legacy List – Current Listings Online Deputy Checklist Sales Reports Schoology Teachers Guide Shop Requests (NEW) The Chronicle This field is hidden when viewing the formEmail* Campus*AvondaleCadenceCasa GrandeChandlerDeer ValleyEast MesaEast TucsonGilbertGlendaleGoodyearKelleyLaveenLeeLOAMaricopaMesa K-6North ChandlerNorth ValleyNW TucsonPeoriaPhoenixQueen CreekSaenzSurpriseSW Las VegasWalkerWest SurpriseName of Threat Assessment Team Member* First Last Notification of Alleged ThreatOn what date did the alleged threat occur? MM slash DD slash YYYY On what date did the school become aware of the alleged threat?* MM slash DD slash YYYY At approximately what time did become known?* : Hours Minutes AM PM AM/PM Who reported the alleged threat?*Alleged PerpetratorName of Student Who Made the Alleged Threat*Grade*Pre-K (Texas Only)Kindergarten1st-Grade2nd-Grade3rd-Grade4th-Grade5th-Grade6th-Grade7th-Grade8th-Grade9th Grade10th Grade11th Grade12th GradeGender* Male Female ESS Status* Eligible under IDEA for Special Education Eligible under Section 504 In the process of being evaluated for either IDEA or 504 eligibility General Education: no affiliation with ESS Description of the Alleged ThreatWhat was the nature of the threat?* Danger to Self Danger to Others Danger to Self & Others What was the format of the alleged threat?*WrittenSymbolicVerbalWhat is the type of the alleged threat? **DirectIndirectVeiledConditionalWhat was the threat? (Use exact wording, if possible) **Who was the alleged threat made against? Be specific.*A student at Legacy Traditional SchoolA staff member at Legacy Traditional SchoolThe entire school / general school communitySelfInterview of the Alleged PerpetratorPlease use the student's exact wording, when possible. These questions may be adjusted in wording based on the student's age, grade, and needsUntitledWhat threat did you make?*Who was the threat against?*What is your plan to carry out the threat?*Who else knows about this?Is there anything else you want to tell me?*Witness InterviewComplete this section to interview any and all witness to the alleged threat. Witness #1Name First Last Tell me about what you heard or saw.What, exactly, did you see or hear that you believe is a threat? (Use exact wording, if possible).What do you think the student meant?Is there anything else you want to tell me?Witness #2Name First Last Tell me about what you heard or saw.What, exactly, did you see or hear that you believe is a threat? (Use exact wording, if possible).What do you think the student meant?Is there anything else you want to tell me?Personality DynamicsDoes the alleged perpetrator display any of the following characteristics? Check all that apply.Intentional or unintentional leakage of violenceLow threshold for frustrationPoor coping skillsLack of resiliencyFailed relationshipsPerseverates on perceived or real injusticesIndications of depressionNarcissisticAlienatesLacks empathyFeels entitledSuperiority complexExaggerated need for attentionBlames othersLow Self EsteemAnger Management ProblemsIntolerance of others (racial, religious, sexual orientation, etc.)ManipulativeUntrustingClosed social groupCynical or judgmentalInterested in sensational violenceNegative role modelsOccupied with behaviors conducive to facilitating threatN / AFamily DynamicsDoes the alleged perpetrator have any of the following characteristics present in his/her family dynamic? Check all that apply.Inconsistent or difficult parent-child relationshipNormalizes pathological behaviorEasy access to weaponsLack of intimacyFew rulesNo limits or monitoring of TV, internet, or gamingN / ASchool DynamicsDoes the alleged perpetrator have any of the following characteristics present in his/her school life? Check all that apply.Student seems detached from schoolBullying occursRacial or class divisionsInequitable discipline policiesInflexible cultureStudent pecking orderCode of silenceUnsupervised access to computersN / ASocial DynamicsDoes the alleged perpetrator have any of the following characteristics present in his/her social relationships? Check all that apply.Unsupervised access to mediaAssociates with peer groups that bolster violence or violent beliefsDrug/alcohol abuseN / AThreat AssessmentDid the student who made the threat have or seek accomplices?* Yes No Does the student have a specific plan to carry out the threat?* Yes No If there is a specific plan, is it realistic? Yes No Is this the first occurrence of this threat?* Yes No Was a weapon mentioned or implied in the threat?* Yes No Does the student have the means to carry out the plan? Consider access to weapons, access to the victim(s), etc. Yes No Has the student been involved in other conflicts with the intended victim(s)? * Yes No Threat Assessment DeterminationThere is a clear threat. Yes No There are identifiable victims. Yes No There is a plan to carry out the threat. Yes - The plan is fully formed and realistic. Yes - The plan is vague and/or unrealistic. No - There is intent to create a plan, but one has not yet been created. No - There is no plan. After consideration of all objective evidence, do you consider this to be a substantive threat?* Yes No What is the level of this threat? n/a This is not a valid threat. Danger to Self Danger to Others - High Level Threat Danger to Others - Medium Level Threat Danger to Others - Low Level Threat Danger to Self & Others - High Level Threat Danger to Self & Others - Medium Level Threat Next StepsMobile Crisis Yes No Date of Contact MM slash DD slash YYYY Time of contact : Hours Minutes AM PM AM/PM Law Enforcement Yes No Date of Contact MM slash DD slash YYYY Time of Contact : Hours Minutes AM PM AM/PM Intended Victim (Duty to Warn) Yes No N / A (no identified victim) N / A (danger to self) Date of Contact MM slash DD slash YYYY Time of Contact : Hours Minutes AM PM AM/PM NotesUse this space to provide any notes relevant to this investigation, assessment, and determination. AttestationI acknowledge that the information contained within this document is accurate and objective. I am providing this information on my own, without the influence or persuasion from other members of the Threat Assessment Team to make decisions that do not represent my personal judgment as to the validity of this alleged threat, the alleged perpetrator, or any of the evidence contained within. ** Yes No
