H M L Have you had any accidents or done anything reckless lately? 55 III. Significant Persons H M L What is your biggest worry right now? ____________________________________________________________ ____________________________________________________________ H M L What matters to you the most? _______________________________________________________________ IV. Student Safety Plan H M L Will you sign a Student Safety Plan? (If the answer is no, student qualifies as a high risk student) _________________ Note: Committee members should consider answers to the questions and overall demeanor of student when deciding risk Risk Factor Circle one: LOW MEDIUM HIGH ________________________________ ________________________________ Committee Member Signature/Title Committee Member Signature/Title ________________________________ Committee Member Signature/Title
H M L Have you had any accidents or done anything reckless lately? 55 III. Significant Persons H M L What is your biggest worry right now? ____________________________________________________________ ____________________________________________________________ H M L What matters to you the most? _______________________________________________________________ IV. Student Safety Plan H M L Will you sign a Student Safety Plan? (If the answer is no, student qualifies as a high risk student) _________________ Note: Committee members should consider answers to the questions and overall demeanor of student when deciding risk Risk Factor Circle one: LOW MEDIUM HIGH ________________________________ ________________________________ Committee Member Signature/Title Committee Member Signature/Title ________________________________ Committee Member Signature/Title
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