ModelofDemonstrationSchool:Application1

RTI2-BModelofDemonstrationSchool

TheTennesseeDepartmentofEducationandTennesseeBehaviorSupportsProjecttogether

willidentifyModelofDemonstrationschoolsand/ordistrictsandasktheseschoolsto

participateincoachingnetworksandcommunitiesofpracticetoassistinimplementation

effortsofotherschools.TheModelofDemonstrationSchoolsprocessisdesignedtorecognize

schoolsforsuccessfulimplementationofResponsetoInstructionandInterventionforBehavior

(RTI2-B).Thepurposeofthisrecognitionistopromoteschoolssharingtheirpractices,share

examplesofhowtheframeworkisbeingimplemented,andcelebrateeachschool’seffortand

dedicationtomeetingtheneedsofallstudents.Alongwithotherformsofrecognition,RTI2-B

ModelofDemonstrationSchoolswillbefeaturedonourwebsite,publicizedduringtrainings

andworkshops,andsharedwithTDOE.

RequirementsforSubmission

TobeconsideredforrecognitionasaBronze,Silver,GoldorPlatinumRTI2-BModelSchoolof

Demonstration,pleasecompleteallfieldsonthisapplicationwithyourschool’sinformation.

SchoolsmustreapplyeachyeartobeconsideredaModelofDemonstrationSchool.1. SchoolswillbeselectedforrecognitionbasedontheirTFIscoresandresponsestothe

application.

2. SchoolsmustattendourRTI2-BTierITrainingbeforecompletingthisapplication.3. TheTieredFidelityInventory(TFI)isrequiredforalllevelsofrecognition.For

informationandinstructionsoncompletingtheTFI,pleasecontactus.

4. UploadandsubmitthisapplicationwithadditionaldocumentsonlineatTBSPatUT

Knoxville’swebsitehttp://etbsp.utk.edu

5. Thisdeadlinetosubmitthecompletedapplicationwithadditionaldocumentsis

December1.

Ifyouhavequestionsorneedhelpwiththeapplicationpleaseemailusattbsp@utk.edu

ModelofDemonstrationSchool: Application2

Date

ApplicationforModelofDemonstrationSchool

Website

Total # of students enrolled

(mm/dd/yyyy)

Contact InformationFull Name

Position

Email

School Information

School Name

District Name

Phone Number

Principal Name

Principal Email

Grade Levels served (choose 1 that best fits your school population)

ModelofDemonstrationSchool:Application3

RTI2-BSchoolTeam MembersPlease include the full name and requested information for up to 10 team members.

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2.

3.

4.

5.

6.

7.

8.

9.

10.

External Coach Name Email

RTI2-B Team Lead Name Email

Team Member Name Position

Team Member Name Position

Team Member Name Position

Team Member Name Position

Team Member Name Position

Team Member Name Position

Team Member Name Position

Team Member Name Position

ModelofDemonstrationSchool:Application4

RTI2-B Workshop Attendance

Schools must attend our Tier I Training before completing this application. Please indicate the most recent TBSP trainings your school attended along with the month and year completed:

TierI Workshop

TierII Workshop

TierIII Workshop

OtherRTI2-Btrainings

DetailsforEachLevelofRecognition

This school is applying for the following level of recognition (see requirements for each level below and please select only 1 from the following):

Bronze EarnedforusingtheTFIandcompletingtheapplication

Silver Earnedforachievingatleast80%onTierIoftheTFIandcompletingthe application

Gold Earnedforachievingatleast80%onbothTierIandoneadditionaltierofthe TFIandcompletingtheapplication

Platinum Earnedforachievingatleast80%onallthreetiersoftheTFIand completingtheapplication

(mm/yy)

(mm/yy)

(mm/yy)

(mm/yy)

ModelofDemonstrationSchool:Application5

Tiered Fidelity Inventory (TFI)

The TFI must be completed for all levels of recognition. TFI scores reported must be from the current school year. For instruction or help on completing the TFI, use this link to contact us.

• What date was the TFI last completed at your school:

• Who was the external coach (TBSP staff or District Coach) who helped the teamcomplete the TFI?

Tier I Score on the TFI

Tier II Score on the TFI

Tier III Score on the TFI

Tiered Fidelity Inventory Scores

ModelofDemonstrationSchool:Application6

AdditionalQuestions

HowlonghasyourschoolbeenimplementingRTI2-B?

Whatareyourschool’stopthreeschoolimprovementgoals?

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2.

3.

What are some of the improvements your school has seen since you began implementing RTI2-B? (e.g., attendance, school climate, suspension rates, academics, etc.)

What are some barriers you encountered with implementing RTI2-B at your school and how did you overcome them?

Please include any other information you would like to share regarding the unique features of RTI2-B at your school.

Tiered Fidelity Inventory (TFI) Scores

The TFI must be completed for all levels of recognition. TFI scores reported must be from the current school year. For instruction or help on completing the TFI, email us at tbsp@utk.edu.

• What date was the TFI last completed at your school:

• Who was the external coach (TBSP staff or District Coach) who helped the teamcomplete the TFI?

Tier I Score on the TFI Tier II Score on the TFI Tier III Score on the TFI

ModelofDemonstrationSchool:Application7

Permissions

Pleasechecktheboxbelowregardingpermissiontouseinformationandquotesprovidedin thisapplicationaspartofourtestimonies.

You have my permission to use my answers for testimonial quotes.

You do not have my permission to use my answers for testimonial quotes.

AdditionalDocuments

Wemayaskforfurtherinformationafterreviewingyourapplication.Pleasebeprepared whensubmittingthecompletedModelofDemonstrationSchoolApplicationtosubmit the followingadditionaldocumentsaspartofthisapplication.

• Yourschool’scurrentRTI2-B implementationmanual

• Yourschool’smostrecentTieredFidelityInventory(TFI)

Submission

This deadline to submit the completed application with additional documents is December 1. Submit completed application and additional documents to our website at etbsp.utk.edu