Threat Assessment Threat Assessment Checklist for School Staff

Student Name:____________________   

Threat Assessment Checklist: The purpose of this form is to comment on the risk factors for potential violence by students who made a threat verbally, in writing or in a drawing. Protective action will need to be taken when risk factors are numerous and/or severe. If the risk factors are numerous,  insure that the appropriate administrator is notified immediately. **Please note: Consultation with your local Police Department is recommended if the items regarding weapons are checked.

The Threat Assessment Team/Counselor has assessed the above student as having the following risk factors for potential violence (check all that apply and comment where indicated)

___ has access to the following weapons:

___ appears to have a fascination with weapons

___ is knowledgeable and/or has used weapons

___ has made recent threats to act out violently

___ has provided evidence of making plans to act out violently:

___ has a history of bringing a weapon to school

___ identifies contingencies that would provoke an act

___ is brooding over an event where he or she was unfairly treated or humiliated:

___ has experienced the following recent life stressor or event:

___ has conveyed a sense of recently being treated unfairly

___ expresses unreasonable feelings of being persecuted by other students or staff

___ appears to be a loner and reveals having no close friends

___ has a history of being bullied or teased dating back to elementary years

___ does not show concern for legal and personal consequences

___ has threatening and/or loud speech

___ is observed during the interview as maintaining prolonged stares

___ is observed as having signs of agitation during the interview: pacing, clenching fists and teeth 

___ reveals feelings of depression, hopelessness, or despair

___ appears to lack appropriate empathy for the victim (s)

___ refuses to communicate with staff

Based on the above risk factors as assessed on this date, the Threat Assessment Team has concluded that the above student poses the following risk for potential violence:

____High Risk for potential violence     ___Low Risk for potential violence

Summary/Recommendations/Action Plan:

 

________________________________     __________

Staff Signature                                                 Date