PIT Referral 2020-21
This form is for staff members to request a student be put on the PIT team agenda. PIT Team referrals are reviewed in a bi-monthly meeting that includes an Administrator, School Nurse, School Social Worker, Counselor and PAC.  We meet bi-monthly on friday's and discuss students that you are very concerned about.  Any information shared in this form is for the use of the PIT team and will be used to help you with your student.  The student will be assigned to a PIT member that will coordinate your student's referral.  If the basis for your referral is to report any abuse, neglect, or intent to harm, you are required to contact the Department of Children's Services at 877-237-0004.  Thank you for helping us  better serve our students.
Sign in to Google to save your progress. Learn more
Email *
Your last name *
Your first name
Student's Last Name *
Student's First Name *
Student's grade (number or letter only. Ex. K or 3) *
Reason for referral: Check all that apply *
Required
Number of absences
Number of tardies
Brief description of issue: *
Addition Helpful Information: Please answer as many as possible. Your answers will help us understand the student's issues more comprehensively.
Caregiver Information: Student lives with
Clear selection
Have you spoken to the caregiver about this situation?
Clear selection
Caregiver contact comments:
Please note any interventions or strategies you have tried prior to referring:
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Knox County Schools. Report Abuse
Google Forms