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Chris Borgmeier, PhD

Portland State University

cborgmei@pdx.edu

www.tier2pbis.pbworks.com www.functionbasedthinking.com

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Adapted 2007, by Rob Horner, Anne Todd, & Celeste Dickey,

Check-In / Check-Out Self-Assessment

School: ___________________________ Date: ___________________

Instructions: As a team, review and record each of the CICO elements. For all elements

that are rated as “in progress” or “not in place” build action planning steps.

CICO Element

In Place

In Progress

Not In Place

Faculty and Staff Commitment for CICO

Team Defined and Available to Monitor Fidelity &

Outcomes with Administrator Represented

FTE available for CICO coordinator

Communication between teams established (e.g., PBS,

CICO, SST)

School-wide PBS in place

Student Identification Process for CICO

Daily CICO progress report card developed

Home report process defined

Point Trading System established

Process for collecting, summarizing and using data

Morning check-in routine established

Teacher check-in/ check-out routine established

Afternoon check-out routine established

Home review routine established

Team meeting schedule, routine, process

Planning for Success/Fading

Planning for Individualized Support Enhancement

Substitute Teacher routine

Playground, cafeteria, bus routine

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Adapted by C. Borgmeier (2014) from B. Stiller (2008)

IPBS Meeting Template

Coordinator: Recorder:

Time Keeper: Date: ____/____/_____

ATTENDING Name X Name X

Admin. Tier 2 Coordinator

Beh Specialist Beh Specialist

I. REVIEW AGENDA: Determine whether changes are needed (2 minutes)

II. REVIEW TASKS FROM PREVIOUS MEETING: Document status of tasks (10 minutes)

Action Who When Status

Not In Done Not

started progress Needed

Not In Done Not

started progress Needed

Not In Done Not

started progress Needed

Not In Done Not

started progress Needed

III. TIER 2 – TARGETED INTERVENTION SUMMARY (15 minutes **3 minutes or less/student)

a. Students on each targeted intervention (Tier 2 Coordinator)

i. # students on CICO & # students meeting goals (80% of pts; 80% of days)

ii. # students on other Tier 2 interventions & # students meeting goals

b. Students not meeting goals, determine problem and next steps **(3 minutes or less/student)

i. Possible problems: Low Fidelity/ Intervention needs to be Modified / Intervention

mismatched to Function of Behavior

ii. Possible decisions: Improve Fidelity / Change Intervention (Tweak) / Preliminary FBA to

match to Intervention / Refer to Tier 3

c. Tier 2 Systems Check

i. Possible problems: Inconsistent Data/Low Fidelity/Low Success Rate/Limited Capacity

ii. Possible decisions: Train Staff/Improve Fidelity/Evaluate Interventions / Increase Capacity

Student/System Problem Decision/Action Who When

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Adapted by C. Borgmeier (2014) from B. Stiller (2008)

IV. TIER 3 – INTENSIVE INTERVENTION SUMMARY (15 minutes **3 minutes or less/student)

a. Students receiving Tier 3 intervention (assigned Behavior Specialist/Case Manager)

i. # students on intensive interventions & # students meeting goals

b. Students not meeting goals, determine problem and next steps

i. Possible problems: Low Fidelity, Intervention/Function mismatch, Intervention needs to be

modified

ii. Possible decisions: Meet with teacher, change intervention, conduct formal FBA

c. Tier 3 Systems Check

i. Possible problems: Inconsistent Data/Low Fidelity/Low Success Rate/Limited Capacity

ii. Possible decisions: Train Staff/Contextual Fit & Implementation Supports/Re-evaluate

Function & Intervention/Access Specialist/ Increase Building Capacity (Basic FBA 2 BSP)

Student/System Problem Decision/Action Who When

V. NEW REFERRALS TO IPBS (10 minutes **2 minutes or less/student)

a. Possible Referral sources:

i. Discipline Referral Data (decision rule?)

ii. Request for Assistance

iii. Behavior Goals added to IEP

Student Referral

source

Decision Who When

Continue Begin Tier 2 Basic Academic Formal

Monitoring intervention FBA assessment FBA

Continue Begin Tier 2 Basic Academic Formal

Monitoring intervention FBA assessment FBA

Continue Begin Tier 2 Basic Academic Formal

Monitoring intervention FBA assessment FBA

Continue Begin Tier 2 Basic Academic Formal

Monitoring intervention FBA assessment FBA

VI. EVALUATION OF MEETING Our Rating (Mark w “X”)

Yes So-So No

1. Was today’s meeting a good use of our time?

2. In general, did we do a good job of tracking & completing the tasks we agreed

on at previous meetings?

3. In general, are we efficient & intervention focused in our discussion of students?

4. Are the completed tasks having the desired effects on student behavior?

If some of our ratings are “So-So” or “No,” what can we do to improve things?

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C. Borgmeier (rev. 2014) Portland State University

Intensive PBS Meeting Review

School Date

Meeting Facilitator Observer

Yes

(2)

Part

(1)

No

(0)

Meeting Preparation

1. Are the right people at the meeting? □ Administrator □ Behavior Specialist (s)

□ Targeted Intervention manager(s) □ Special Education representative

2. Was a meeting agenda presented?

3. Were meeting roles established?

□ Facilitator □ Time Keeper □ Recorder □ Data Analyst

Review Action Items 4. Reviewed Action Items & tasks assigned at previous meeting

Progress Monitoring – Secondary Interventions 5. Was data prepared and reviewed to monitor progress of students currently receiving

secondary/targeted interventions?

6. Was student success reported and celebrated?

7. Was data used (e.g. ODR’s, CICO, Brief FBA) to inform intervention decisions for students?

8. Were decision rules followed to identify students requiring add’l intervention?

9. Were interventions for individual students documented w/ assigned tasks?

10. Were individual student conversations completed efficiently (< 3 minutes per student)?

Progress Monitoring – Tertiary Interventions 11. Was data prepared and reviewed to monitor progress of students receiving tertiary intervention?

12. Was student success reported and celebrated?

13. Was data used (e.g. ODR’s, CICO, FBA) to inform intervention decisions for students?

14. Were decision rules followed to identify students requiring add’l intervention?

15. Were interventions for individual students documented w/ assigned tasks?

16. Were individual student conversations completed efficiently (< 3 minutes per student)?

Screening & Student Identification 17. Was data prepared and reviewed to identify students requiring individual behavioral support?

□ Screening data □ ODR data □ Referral (teacher, parent, etc.)

18. Were interventions assigned for students identified for secondary/targeted behavioral

interventions in an efficient manner (< 2 minutes per student)?

Systems Monitoring

19. Were data reviewed to identify the need, implementation fidelity and effectiveness of

targeted/secondary interventions (CICO, etc.)?

Meeting Follow-Up 20. Was the meeting agenda followed during the meeting?

21. Was data prepared in advance for quick review and presentation?

22. Was the meeting completed in the scheduled time?

23. Is a next meeting scheduled within the next 2 school weeks?

_____ / 46 = ______ % I-PBS Meeting Score

NOTES:

Strengths 1.

2.

Grows 1.

2.

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Adapted from the Tiered Fidelity Inventory

Targeted Interventions Reference Guide Map

School Date

List your targeted interventions in the Top row and identify supports each provides or

student needs met (function) in the column below each intervention.

TARGETED INTERVENTION

Check-In/ Check-Out

TIER 2 Capacity: How many students can we effectively support now?

#

Access to Adult Attention Yes

Access to Peer Attention Yes

Access to Choice of Alternatives/Activities

Yes

Option for Avoiding Aversive Activities/Task

Yes

Option for Avoiding Aversive Peer/Adult Attention

Yes

Structural Prompts for “What to do” throughout the day

Yes

At least 5 times during the day when positive feedback is set up

Yes

A school-home communication system

Yes

Opportunity for Adaptation into a self-management system

Yes

Instruction of Expected Skills/Behaviors

Yes

a) How does your total capacity for Tier 2 Interventions compare with the projected need?

b) Are there specific types of supports or areas of student need that require more Tier 2 Supports?

Projected Number of Students who would benefit from Tier 2 Supports:

School Enrollment x .10 = Students

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Adapted from the Tiered Fidelity Inventory

Targeted Interventions Reference Guide Map

School SAMPLE MS Date 2/12/15

List your targeted interventions in the Top row and identify supports each provides or

student needs met (function) in the column below each intervention.

TARGETED INTERVENTION

Check-In/ Check-Out

Social Skills

Club

Peer Mentors

Homework Club/ ABC

CICO

TIER 2 Capacity: How many students can we effectively support now?

20 8 4 15

Access to Adult Attention Yes Yes No Yes

Access to Peer Attention Yes Yes Yes Yes

Access to Choice of Alternatives/Activities

Yes No Yes No

Option for Avoiding Aversive Activities/Task

Yes No No No

Option for Avoiding Aversive Peer/Adult Attention

Yes No Yes No

Structural Prompts for “What to do” throughout the day

Yes No No Yes

At least 5 times during the day when positive feedback is set up

Yes No No No

A school-home communication system

Yes No No Yes

Opportunity for Adaptation into a self-management system

Yes No No Yes

Instruction of Expected Skills/Behaviors

Yes Yes Yes Yes

a) How does your total capacity for Tier 2 Interventions compare with the projected need?

Projected need = 65-80 students; Capacity = 47 students.. feel we could serve students more effectively

by increasing capacity of CICO to 25 students (several students we’d like on CICO now, but no space)

b) Are there specific types of supports or areas of student need that require more Tier 2 Supports?

Need more options for students seeking to avoid task; considering “Breaks are Better” or modifying “ABC

CICO”

Projected Number of Students who would benefit from Tier 2 Supports:

School Enrollment 650 x .10 = 65 Students

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BREAKS ARE BETTER Point Card

Name: ________________________________________ Date: ________________

2 = great job 1 = OK, try again 0 = hard time

Breaks Are Better

Class Safe Responsible Respectful 2 Minute Breaks I can

take

Took Breaks appropriately

(if needed) Check-In 0 1 2 0 1 2 0 1 2

0 1 2 0 1 2 0 1 2 O O O Y N

0 1 2 0 1 2 0 1 2 O O O Y N

0 1 2 0 1 2 0 1 2 O O O Y N

0 1 2 0 1 2 0 1 2 O O O Y N

0 1 2 0 1 2 0 1 2 O O O Y N

0 1 2 0 1 2 0 1 2 O O O Y N

0 1 2 0 1 2 0 1 2 O O O Y N

Check-Out 0 1 2 0 1 2 0 1 2

Today’s Goal:

_____ points

Today’s Total Points Number of Breaks Used

Parent’s Signature

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ABC Point Card Name : Date:

SW Rules ABC Goals Soc’l Studies Lang Arts Math Writing Science

Be Safe Ask for Help Appropriately 2 1 0 2 1 0 2 1 0 2 1 0 2 1 0

Be Respectful Participate in Class 2 1 0 2 1 0 2 1 0 2 1 0 2 1 0

Be Responsible Complete Class Assignments

2 1 0 2 1 0 2 1 0 2 1 0 2 1 0

Do Your Best Record assignments on Checklist

2 1 0 2 1 0 2 1 0 2 1 0 2 1 0

Points: 2 = Met Expectations (Great Job!) 1= Met some Expectations (Good Job!) 0=Did not meet Expectations (Room for Improvement)

Check-In Bonus Points (1 point each): _____ Was Prepared _____ Had all Homework (HW)

Today’s Goal: ___________ Today’s Total _______________

Parent Signature: _____________________________________ Date: _________________ _____ My child completed all HW due ______ My child has not completed all HW due

ABC Homework Tracker Class Assignment Due

Date Teacher Signature

Completed

Soc’l Studies

Y N IP

Lang Arts

Y N IP

Math

Y N IP

Writing

Y N IP

Science

Y N IP

Additional Homework Notes:

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Tier 2 (Secondary) Interventions Tracking Tool

School Name: _____________________________ School Total Pop as of October 1:________

Interventions Check-in Check-out

(CICO)

# Students Participating

# Students Responding

# Students Participating

# Students Responding

# Students Participating

# Students Responding

# Students Participating

# Students Responding

# Students Participating

# Students Responding

# Students Participating

# Students Responding

July

August

September October November December January February March April May June

Data-based Decision-rules for defining “response to intervention”: Please list below your data-based decision-rule to determine youth ‘response’ for each of the six levels of intervention. Ex. Students received 80% or better on Daily Progress Report for 4 consecutive weeks. Responding to Check-in Check-out (CICO): Responding to Lunch Buddies: Responding to Homework Club: Responding to….

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Tier 2 (Secondary) Interventions Tracking Tool

School Name: _____________________________ School Total Pop as of October 1:________

Check-in Check-out (CICO) Lunch Buddies Homework Club

Interventions # Students

Participating # Students Responding

# Students Participating

# Students Responding

# Students Participating

# Students Responding

# Students Participating

# Students Responding

# Students Participating

# Students Responding

# Students Participating

# Students Responding

September 7 5 13 ? 0 0 October 10 7 14 ? 13 5 November 12 9 27 ? 19 7 December 13 9 27 ? 25 8 January 19 15 41 ? 29 8 February 21 16 43 ? 39 11 March 26 21 47 ? 47 14 April 28 22 65 ? 65 20 May 29 23 67 ? 78 23 June 29 23 67 ? 79 23

Data-based Decision-rules for defining “response to intervention”: Please list below your data-based decision-rule to determine youth ‘response’ for each of the six levels of intervention. Ex. Students received 80% or better on Daily Progress Report for 4 consecutive weeks. Responding to Check-in Check-out (CICO): Responding to Lunch Buddies: Responding to Homework Club: Responding to….

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Multi-Tiered Action Plan (MAP) Page 1 of 3

v8.20.09

Developing a Multi-Tiered School-wide PBIS Action Plan

The objective for developing a School-wide PBIS Multi-Tiered Action Plan is to define a systematic plan for improving school

climate, discipline and behavior support for ALL students. The Action Plan should be completed in the last quarter of each school

year to define Goals and Actions for sustaining PBIS and continuous improvement of implementation across tiers. Integrating

information from several data sources is very useful when designing an action plan.

The following guidelines should be considered when completing the PBS Annual Action Plan.

1. Develop the PBS Annual Action Plan as a team.

2. Identify data sources and analyze data

3. Set long (1-2 year) and short (3,6, & 9 month) term objectives

4. Be specific about “who” will be responsible for each activity

5. Reference this Action Plan to monitor your progress throughout the year.

The Multi-Tiered PBIS Action Plan should consider the implementation features in the Checklists below:

Tier 1 Tier 2 Tier 3

Finalize Team members & meeting

schedule for Upcoming Year

Develop PBIS Teaching schedule for

1st week and school year

Staff-wide Training & Updates

Identify any needs/changes to:

School rules/ expectations

Instructional event

Acknowledgement system

Corrections & Referral Process

Data Systems & Process

Updates to PBIS Handbook

Bully Prevention

Classroom Supports

Family Training & Participation

Finalize I-PBIS Team members &

meeting schedule for Upcoming Year

ID Targets for Improving I-PBIS

Meeting Processes

Staff-wide Training & Updates

Plan for CICO personnel/ FTE

(Coordinator & Specialists)

Update CICO & I-PBIS Handbook

Review Fidelity of CICO & Capacity

Improvements/ Adjustments to CICO

CICO Data System needs

Identify students to begin year on

CICO

Additional Tier 2 Intervention Needs

Family Training & Participation

Identify Behavior Specialists and

Capacity/Needs

Review FBA/BSP Fidelity &

Processes & ID Targets for Dev’t

Staff-wide Training & Updates

Training All Staff on Function-Based

Thinking

Update Tier 3 – FBA/BSP Handbook

Identify students to begin year on

FBA/BSP & plan for Implementation

Tier 3 Data System Needs

Review District Support, Family

Participation & Community Supports

Family Training & Participation

Evaluation Tools/Measures Evaluation Tools/Measures Evaluation Tools/Measures

SET, BOQ, TIC, SAS

Discipline Referral Data, School

Climate Surveys, Attendance

CICO Self Ax, MATT, BAT

CICO Data (Effectiveness &

Capacity)

MATT, BAT, BSP Critical Features

Checklist

Student Outcome & Fidelity Data

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Multi-Tiered Action Plan (MAP) Page 2 of 3

v8.20.09

School Name: Year Date Directions: 1. Use one action plan to coordinate all of the building’s PBIS implementation steps. This is a sample format; others can be used for the same purpose. 2. Sources of actions steps come from trainings, steps for sustaining implementation as well as tools such as SET, MATT, SAS, CICO Self Ax, etc.

Tier/Topic Evidence/Data that Identifies Need

Next Steps Action Who? When?

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