€¦ · Web viewFidelity of implementation is the delivery of instruction in the way in which it was designed to be delivered and researched to be effective (Gresham, MacMillan,

Early I.S.D.

Response to Instruction&

Intervention

“The Prescription for student success”2016-2017

Early I.S.D. “Response to Instruction/Intervention Checklist”

Tier 1-Classroom Explicit Instruction Student Name: _________________________ Grade:______Teacher:____________________ Date:_________

All forms can be found on the RTI webpage for Early I.S.D.

➢ Core curriculum taught with fidelity and differentiated instruction provided Yes No

➢ Initial RTI Problem Solving for Tier 1 meeting includes the following based on campus:

· Teacher, RTI Campus personnel, and Principal at the classroom, grade, or campus level

· Complete Information from Education Record (school counselor)

· Vision and hearing screening (school nurse)

· Learning Behavior Checklist available in RTI Toolbox (teacher)

Yes No

➢ Teacher identifies student needing intervention instruction through multiple assessment measures (Attach report or document score)

· iStation Score _____________

· Benchmark Assessments Score _____________

· State Assessment Data Score _____________

· Star Reading Score _____________

· Learning Behaviors Checklist Attached __________

· Teacher Observation Attached __________

· Other Observations Attached __________

· Rating scales or checklists Attached __________

· Behavior logs Attached __________

Yes No

➢ Collect 3-6 points of data (6-8 weeks minimum)

· Classroom instruction and purposeful, planned small groups

Yes No

➢ Is student receiving services outside of classroom services? Yes No

➢ Documentation of parent contact(s)

· Use of parent contact log

Yes No

➢ Prior to scheduling an RTI meeting:

· Complete highlighted information on Response to Intervention and Instruction Record and email to

Campus RTI Connection and District RTI Coordinator

· When all information is complete, Campus RTI Coordinator will place student on RTI Schedule

Yes No

Early Independent School District “Parent Contact Log”

Date: _________________

To the Parents of __________________________,

Deliberations: ___________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Date: _________________

To the Parents of __________________________,

Deliberations: ___________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Date: _________________

To the Parents of __________________________,

Deliberations: ___________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Tier 1 - LEARNING BEHAVIORS CHECKLIST

Student: _______________________________ Date: __________ Grade Level: ____ Teacher: __________________________

*Teacher(s), please review and check the behaviors impacting academic performance. *

READING WRITING

___ Does not comprehend what is read___ Does not finish assignments due to reading difficulty

___ Does not use word attack skills___ Omits, adds, substitutes, or reverses letters, words, or sounds when reading

Attach Additional Information:

___ Unable to copy letters, words, sentences, and numbers from a model___ “Reverses” letters and numbers

___ Does not compose complete sentences or express complete thoughts in writing___ Does not organize writing activities

___ Unable to copy simple designs


MATHEMATICAL CALCULATIONS/CONCEPTS___ Does not understand abstract concepts___ Fails to correctly solve (+/-/x) problems

___ Does not know/remember facts___ Has difficulty solving math word problems


SPELLING___ Has difficulty with phonetic approaches

___ Omits, substitutes, adds, or rearranges letters or sounds when spelling___ Requires continued drill and practice to learn spelling words

___ Appears to memorize words rather than understand their spelling rules


SPEAKING___ Had difficulty imitating speech sounds

___ Distorts or mispronounces sounds/words___ Not fluent when speaking

___ Does not complete thoughts when speaking___ Has a limited speaking vocabulary


LISTENING___ Does not follow verbal directions

___ Has difficulty differentiating speech sounds heard___ Requires eye contact in order to listen successfully


MEMORY/ORGANIZATION___ Disorganized

___ Limited memory skills VISUAL/AUDITORY___ Requires slow, sequential, presentation of directions/concepts


ATTENTION___ Has difficulty staying on task

___ Doesn’t complete task before moving on to another___ Begins work impulsively without direction

___ Easily distracted


INTERPERSONAL RELATIONSHIPS___ Has little or no interaction with teachers___ Has little or no interactions with peers

___ Bothers other students___ Cannot work appropriately in small groups

___ Is unable to keep hands to self in small groups___ Appears to always be the victim


MOTIVATION/EMOTIONS___ Avoids situations, assignments, and responsibilities

___ Ignores consequences of behavior___ Does not appear to care about academic performance or incentives

___ Easily agitated/hostile___ Does not take responsibility for actions


Options for Documenting Student’s StrengthsGeneral Strengths· Is able to work or play independently· Is interested in doing well

· Understands and sets goals· Wants to/is eager to learn new things· Asks for help when needed

· Works well/gets along well one-on-one· Is able to organize items and thoughts· Admits disappointments/mistakes and is able to move on· Has passions and hobbies· Can plan ahead· Makes good choices· Is curious and creative· Problem-solves well Social Strengths· Shares, takes turns and negotiates· Seeks out social interactions· Asks for help and comfort when needed· Accepts personal responsibility for actions (good and bad)· Has a good sense of humor· Follows rules and routines well· Accepts redirection well· Is able to make friends and keep them· Is truthful and honest· Has positive relationships with adults· Shows empathy and sensitivity to others· Likes to help others· Reacts appropriately when frustrated (such as not hitting)

Language Strengths· Is able to express needs, wants and ideas verbally· Uses inflection and expression when speaking· Understands jokes, puns, and riddles· Can talk about events in the correct and logical order· Understands the give-and-take of conversation· Uses grammar appropriate to his/her age· Has and uses a growing vocabulary

· Is interested in listening to stories, music, and other activities· Participates in discussions at home, at school and with friends· Answers who, what when, where questions in conversation (or about a story)

Literacy Strengths· Enjoys reading· Can match letters to sounds and sounds to letters· Is able to sound out unfamiliar words· Recognizes sight words· Can follow written directions· Recalls and retells stories and facts

INSTRUCTION/INTERVENTION PLAN

Student: __________________________________________ Date: _______________________ Grade: ________________Tier Level Addressed

Tier 1 Tier 2 Tier 3

Concern(s) to be Addressed· Number of concerns addressed in this instruction/intervention plan: (Circle one) 1 2 3 4· It is recommended to focus on the top 1 or 2 concerns at a time.· Obtain and use one “Instruction/Intervention Plan” form for each identified concern.

Developing the Plan

1. Concern # _______ of _______ Academic Behavior

State concern:

As a team, hypothesize the reason for the above concern: _________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

2. Goal for Concern-

How will this goal be measured:

3. Brainstorm-List possible intervention strategies/accommodations & choose 1 or 2 of the best to meet the Goal for this

concern:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

4. Resources and/or Materials-List available resources and/or materials to assist in the implementation of the intervention(s):

______________________________________________________________________________________________________

______________________________________________________________________________________________________

5. Motivation/Incentive Strategies-List strategies that will have the greatest impact on the success of the student:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

6. Person(s) Responsible/Schedule-List all personnel to deliver instruction/intervention and collect data:

Person(s): ___________________________________ Group Size: ______ Location(s): ______________________________

Strategy(s): ____________________________ __________________________ ______________________________________Days: Mon. Tue. Wed. Thur. Fri. Time(s): __________ __________

7. Monitoring Procedure(s)-Describe how the instruction/intervention(s) will be monitored and attach copies or samples that

provide evidence of your monitoring: _________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Monitoring Period: Begin date: __________ End date: __________Weeks 1-2

Dates:________________________________________________________________________________________

Results:________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Progress toward goal(s): Significant progress Some progress No progressWeeks 3-4

Dates:________________________________________________________________________________________

Results: _______________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________


Dates:________________________________________________________________________________________

Results: _______________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________


Dates:_________________________________________________________________________________________________

Results: _______________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Progress toward goal(s): Significant progress Some progress No progress

Information from Educational Records School Counselor to Complete before Tier 2 Mtg.

RTI Committee Referral Secondary Tier 3 Evaluation Date: ____________

Initial Tier 2 Referral

504 Committee Referral

Parent Referral

Student Name: _________________________________________________Social Security Number: _______________________ Date of Birth: _____________________Campus: _____________________________________ Grade Level: _____________________

Academic/Functional Areas of Concern:

Basic Reading Skills Math Computation

Reading Fluency Math Reasoning

Reading Comprehension Written Expression

Articulation Receptive Language

Behavior/Attention Expressive LanguageOther: _________________________________________________

*Students with medical or health issues must be referred to the campus 504 committee first. The 504 committee will make the decision to refer the student to Special Education if necessary. 504 documentations must be attached.

Has this student been retained? If YES, list grade level(s): __________YES NO

Has this student had excessive disciplinary referrals during the current school YES NO year? If YES, attach documentation .

Please attach a copy of the following data:___Report Card (last 3 years) ___LEP Evaluation/Report/Documentation (if applicable)___Attendance Report (last 3 years) ___High School Transcript (most current)___STAAR/TPRI/iStation (last 3 years) ___Dyslexia Evaluation/Report (if applicable)

___Home Language Survey ___External Evaluations (if applicable)medical/psychological/vision/hearing…

___Vision/Hearing Screening (current year) ___504 Evaluation/Report/Documentation (if applicable)List ALL schools previously attended: ___________________________________________________________________________________

________________________________________________________________________________________________________________

Check the area of current eligibility or RTI concern. For initial referrals, chick ONLY the area of concern in which RTI strategies have been implemented and found to be effective. RTI documents must be attached.

Tier-1 EDUCATIONAL SCREENING/EXISTING EVALUATION DATAHEALTH INFORMATION

Date: __________ Student Name: __________________________________ Date of Birth: ______________Campus:_____________________________________ Grade: _________________

Vision:Date of most recent screening: _________________ Type of Screening:___________________________Name of person conducting screening:____________________________________________________________

Far Vision: or Near Vision:Results: Right __________ within normal limits? _____YES _____NO Left __________ within normal limits? _____YES _____NO Corrective lenses? _____YES _____NO Informal screening indicates vision is WNL for evaluation purposes: _____YES _____NOTested with corrective lenses: _____YES _____NO

_____YES _____NO As a result of the screening, is there any indication of a need for further assessment or adjustment? If YES, explain: ___________________________________________________________________________________________________YES _____NO Has any follow-up treatment been recommended? If YES, explain: ____________________________________________________________________________________________________________________________________

Hearing:Date of most recent screening: _________________ Type of Screening:___________________________Name of person conducting screening:____________________________________________________________

Results: Right: Threshold within normal limits? ___ YES ___NO ___500 ___1K ___2K ___4K Left: Threshold within normal limits? ___YES ___NO ___500 ___1K ___2K ___4K

Tested with hearing aids: _____YES _____NO

_____YES _____NO As a result of the screening, is there any indication of a need for furtherassessment or adjustment? If YES, explain: _______________________________________________________________________YES _____NO Has any follow-up treatment been recommended? If YES, explain:____________________________________________________________________________________________________________________________________

Health:_____YES _____NO Does student exhibit any signs of health or medical problems? If YES, citeobservations: ______________________________________________________________________________________YES _____NO Is there a need for further assessment or referral of a medical problem? If YES, explain:__________________________________________________________________________________________________YES _____NO Is student receiving any medication at school? If YES, specify:_________________________________________________________________________________________________________________________YES _____NO Does this student require adaptive equipment or facility adaptation? If YES, specify:____

_____________________________________________________________________________________________

____________________________________________ ________________________________Signature Position (School Nurse)

Early I.S.D. “Response to Instruction/Intervention”

Tier 2-Small Group Targeted Instruction 2-3 Times a Week in 30 min. sessions Student Name: __________________ Grade:______Teacher:_________________ Date:_________


➢ RTI Problem Solving for Tier 2 meeting includes the following based on campus:

· Primary Campus: classroom teacher, and 2 other staff including- Principal, Campus RTI Coordinator, and District RTI Campus Coordinator

· Elementary/Middle School Campus: teacher of concern (i.e., reading, writing, math), principal, Campus RTI Coordinator and District RTI Coordinator

Yes No

➢ Initial Tier 2 RTI Meeting is for school staff. Yes No

➢ Student’s intervention plan developed and implemented Yes No

➢ Send home “Tier 2 Notification of Response to Intervention Plan” Yes No

➢ Collect 3-6 data points. (6-8 weeks minimum)

· Group size becomes smaller

· Intervention time is in addition to classroom instruction

· Intervention becomes targeted

Yes No

➢ Continue Progress Monitoring

· iStation

· Weekly classroom assessments

· Teacher Observations

· Rating scales or checklists

· Behavior logs

Yes No

➢ Continue parent contact documentation Yes No

➢ Review student progress and intervention plan➢ Adjust intervention means or methods if necessary

· 2 weeks for behavior

· 6 weeks for academics

Yes No

*All core programs need to be taught and intervention plans followed with fidelity.Fidelity of implementation is the delivery of instruction in the way in which it was designed to be delivered and researched to be effective (Gresham, MacMillan, Boebe-Frankenberger, & Bocian, 2000). Fidelity must also address the integrity with which screening and progress-monitoring procedures are completed and an explicit decision-making model is followed. In an RTI model, fidelity is important at both the school level (e.g., implementation of instruction and progress monitoring). National Research Center on Learning Disabilities

Early Independent School District-2

Date: ____________ Grade Level: _______ Homeroom Teacher: _____________________________

To the Parents of __________________________,

As you know, we are committed to helping all students become successful learners and citizens. In an effort to

give your child the most complete educational supports, we are providing him or her with some additional, targeted

instruction during RTI (Response to Instruction/Intervention) time.

This letter is to inform you of our intent to provide some additional time for your child to master skills necessary

for educational success. This does not mean your child is educationally at risk; it is to ensure your child is progressing with

grade level skills in the areas of Math, Science, History, or English Language Arts and Reading.

If you have any questions, please feel free to call your Campus Response to Instruction/Intervention connection

at:

Early Primary Julie Schafer 325-643-9622

Early Elementary Sharon Watson 325-646-5511

Early Middle Susan Hohertz 325-643-5665

Early High Jennifer Kent 325-643-4593

Please sign and return the bottom portion of this letter acknowledging you have received this information, and return to

your child’s teacher or school counselor.

__________________________________________________________ ____________________Parent Signature Date





Developing the Plan


State concern:


______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________




concern:

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______________________________________________________________________________________________________

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Dates:_________________________________________________________________________________________________

Results:________________________________________________________________________________________________

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Dates:_________________________________________________________________________________________________

Results: _______________________________________________________________________________________________

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Dates:_________________________________________________________________________________________________

Results: _______________________________________________________________________________________________

______________________________________________________________________________________________________

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Progress toward goal(s): Significant progress Some progress No progressWeeks 7-8 Dates:________________________________________________________________________________________

Results: _______________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________


Tier 2-Initial Meeting “Evaluation Interventions”· After review of previous intervention plans, answer the following questions.

Describe the intervention(s) tried and the effectiveness of the intervention(s). ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did the intervention(s) result in a decrease in the student’s learning gap and/or problem behavior?

Yes No Explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does progress monitoring data determine the intervention to be effective?

Yes No Explain: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do assessments verify that student performance/behavior has improved?

Yes No Explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Rate the results of intervention(s) attempted?

High Level Improvement Moderate Level Improvement Slight Improvement

No Change Decline

Tier 2-Meeting Minutes_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Tier 2-Initial Meeting Signature Page

Student: _____________________________ Grade: _____ Date: ____________

Conclusion of Meeting· Collect signatures of those in attendance.

➔ RTI Team Leader Signature: ______________________________________

➔ Principal/Administrator Signature: ______________________________________

➔ General Education Teacher Signature: ______________________________________

➔ Sp. Ed. Representative Signature: ______________________________________

➔ ____________________ Signature: ______________________________________

➔ ____________________ Signature:______________________________________

➔ ____________________ Signature: ______________________________________

➔ ____________________ Signature: ______________________________________

➔ Parent/Guardian Signature: _____________________________________


· Provide copies of forms to parent/guardian.

· Provide copies of forms to RTI Team Leader for follow-up information.

· If parent/guardian is not present, contact will be made via:

Phone Mail Note home Meeting

Early I.S.D. “Response to Instruction/Intervention”

Tier 3- 3:1 Group Size Intensive Intervention 5 Times a Week in 30-45 min. sessions

Student Name: _________________________ Grade:______Teacher:____________________ Date:_________


➢ RTI Problem Solving for Tier 3 meeting includes the following:★ Classroom teacher, Members of the original team, Campus and District RTI Coordinators,

Parent(s), Director of SPED, or Curriculum Director, and Principal· States the student’s current progress and intervention plan.· Call and invite parents to attend meeting.· Record invitation date and time recorded on the contact log.

Yes No

➢ Hard copies of pertinent information and data are in student’s RTI file. Yes No

➢ Implementation of intensive plan with fidelity

· Progress Monitor weekly

· Complete plan for 4-6 weeks

Yes No

➢ Send home “Tier 3 Invitation to Response to Intervention Team Meeting” Yes No

➢ Collect 3-6 data points. (6-8 weeks minimum)

· Group size becomes smaller yet

· Intervention time increases

· Intervention becomes strategic

Yes No

➢ Final RTI Meeting to include:

· Classroom teacher, Members of the original team, Campus and District RTI Coordinators, Parent(s)

· If Special Education referral is to be considered, the Director of SPED, or Curriculum Director, and Principal must also be present

Yes No

*All core programs need to be taught and intervention plans followed with fidelity.Fidelity of implementation is the delivery of instruction in the way in which it was designed to be delivered and researched to be effective (Gresham, MacMillan, Boebe-Frankenberger, & Bocian, 2000). Fidelity must also address the integrity with which screening and progress-monitoring procedures are completed and an explicit decision-making model is followed. In an RTI model, fidelity is important at both the school level (e.g., implementation of instruction and progress monitoring). National Research Center on Learning Disabilities.

Early Independent School District-3

Date: _________________

To the Parents of __________________________,

As you know we are committed to helping all students become successful learners and citizens. In an effort to

better serve your child, we are inviting you to attend an intervention meeting about your child on

___________________, _____________________ at ____________ a.m./p.m. The members of this meeting will

include all of the campus RTI committee and will be held in room ________________________ at Early Primary / Early

Elementary / Early Middle / or Early High School.

This meeting is to discuss how your child is progressing with grade level skills in the areas of Math, Science,

History, or English Language Arts and Reading. Your input is valued, welcomed, and appreciated.

If you have any questions, please feel free to call your Campus Response to Instruction/Intervention connection

at:

Early Primary Julie Schafer 325-643-9622

Early Elementary Sharon Watson 325-646-5511

Early Middle Susan Hohertz 325-643-5665

Early High Jennifer Kent 325-643-4593

_____________________________________________________________________________________________

Please return this bottom portion to your child’s teacher or counselor.

_______ Yes, I am able to attend the meeting at the above time.

_______ No, this would be a better time for me to attend an intervention meeting for my child.

_____________________________________________________.

_______ A phone conference, at this date and time _____________________________ would be most convenient for me.





Developing the Plan


State concern:


______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________




concern:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________


______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________


______________________________________________________________________________________________________

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______________________________________________________________________________________________________

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Dates:________________________________________________________________________________________

Results:________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Progress toward goal(s): Significant progress Some progress No progress Weeks 3-4

Dates:________________________________________________________________________________________

Results: _______________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________


Dates:________________________________________________________________________________________

Results: _______________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________


Dates:_________________________________________________________________________________________________

Results: _______________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________


Tier 3-Initial Meeting “Evaluation Interventions”· After review of previous intervention plans, answer the following questions.

Describe the intervention(s) tried and the effectiveness of the intervention(s). ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did the intervention(s) result in a decrease in the student’s learning gap and/or problem behavior?

Yes No Explain: __________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does progress monitoring data determine the intervention to be effective?

Yes No Explain: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do assessments verify that student performance/behavior has improved?

Yes No Explain: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Rate the results of intervention(s) attempted?

High Level Improvement Moderate Level Improvement Slight Improvement

No Change Decline

Tier 3-Meeting Minutes_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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Tier 3-Initial Meeting Signature Page

Student: _____________________________ Grade: _____ Date: ____________

Conclusion of Meeting· Collect signatures of those in attendance.

➔ RTI Team Leader Signature: ______________________________________

➔ Principal/Administrator Signature: ______________________________________

➔ General Education Teacher Signature: ______________________________________

➔ Sp. Ed. Representative Signature: ______________________________________

➔ ____________________ Signature: ______________________________________

➔ ____________________ Signature:______________________________________

➔ ____________________ Signature: ______________________________________

➔ ____________________ Signature: ______________________________________



· Provide copies of forms to parent/guardian.

· Provide copies of forms to RTI Team Leader for follow-up information.

· If parent/guardian is not present, contact will be made via:

Phone Mail Note home Meeting

Early ISD RTI Process-Tier 3 Information from ParentsName___________________________________ SSN______________________ Medicaid #__________________________

School_______________________________________________ Grade____________ DOB _________________________

Address___________________________________________ Phone # _______________ Cell phone #_________________

Family InformationFather: Father’s Name: _______________________________________________________________________________________

Father’s Address: ______________________________________________________ Phone Number: _________________

Father’s Occupation: ___________________________________________________________________

Father’s Highest level of Education: __________________

Mother:

Mother’s Name: ______________________________________________________________________________________

Mother’s Address: ___________________________________________________ Phone Number: ____________________

Mother’s Occupation: ___________________________________________________________________

Mother’s Highest level of Education: __________________

With Whom Does the child live? Both Biological Parents Father Foster Parent Mother Grandparent Other: ________________ Please list any other child or adult living in the home:

Name Age Relationship to the Child

Has your child always lived with you? If NO, please

explain.________________________________________________________

______________________________________________________________________________________________________

Primary language spoken in the home__________________________ Other languages spoken____________________________

Child BehaviorsWhat does your child do when not in school? (For example, watch TV, read, do chores, work at part-time job, play with other children.)______________________________________________________________________________________________________

______________________________________________________________________________________________________

What are some of your child’s strengths? (ie: sports, creativity, music, kindness, work ethic)______________________________________________________________________________________________________

______________________________________________________________________________________________________

Do you feel that your child is experiencing problems in school? What kind of problems?______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

What is your child’s attitude toward school?______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Please describe your child's behavior at home.______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Circle below the characteristics of your child's temperament.

Activity level Low Average High

Attention level Low Average High

Dealing with changes Poor Good Very good

Responding to new things (e.g., places, people, food, etc.)

Poor Good Very good

What is your child's basic mood? Unhappy Average Very happy

Have there been any important changes within the family? (For example, parent job changes, moves, births, deaths, illnesses, accidents, separations, divorce, remarriage)______________________________________________________________________________________________________

______________________________________________________________________________________________________

Briefly discuss any other important information about your child.______________________________________________________________________________________________________

______________________________________________________________________________________________________Health and Developmental HistoryWere there any problems before, during, or immediately after birth? □ Yes □ NoIf yes, please explain.______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Describe any problems during infancy or early childhood with feeding, sleeping, or other areas such as difficulty being comforted, excessive restlessness or irritability, colicky, etc.______________________________________________________________________________________________________

______________________________________________________________________________________________________ Ear Infections: □Yes □No If yes, please indicate how many and when:

________________________________________

Did your child require tubes placed in the ears? □Yes □ No If yes, when? _____________________________________When did your child say his first word? _____________________ Speak in at least 3 word sentences? _______________________ Does your child seem to understand simple directions? _________________

Is your child able to complete multiple step directions without you repeating them? _____________________ Please indicate if your child has experienced any of the following:□Severe Allergies □Asthma □Diagnosed depression □Head injuries□Snoring □Trouble sleeping □ Serious illness/hospitalization □High fever□Seizures □Tonsillectomy/Adenoid □Concussion

□Other___________________Is your child under the care of a physician for a medical problem? □ Yes □ No If yes, please explain.______________________________________________________________________________________________________

______________________________________________________________________________________________________

Is your child now taking medicine? □ Yes □ No If yes, please describe reason for medication, type, dosage, and effect and side effects the medicine might have.______________________________________________________________________________________________________

______________________________________________________________________________________________________

Has your child ever taken medicine for a long period of time? □ Yes □ No If yes, please explain the reasons and effect.______________________________________________________________________________________________________

______________________________________________________________________________________________________

Is your child receiving services from another agency (e.g., tutoring, counseling, probation monitoring, etc.)?

□ Yes □ No If yes, please explain.______________________________________________________________________________________________________

______________________________________________________________________________________________________

Has your child ever been evaluated before for neurological, psychological, psychiatric, speech language, learning, hearing, vision, or physical problems in the past? □ Yes □ No If yes, please explain and indicate dates of assessments.______________________________________________________________________________________________________

______________________________________________________________________________________________________

_______________________________________________ _________________________________________

Signature Date

Classroom Teacher Observation/Checklist Data

Student Name: ____________________________________ Grade: _______ Campus: ________________________________

Date & Time of Observation: _______________________ Length of observation in minutes: __________ (At least 30-45 min)

The observation should be completed IN THE AREA OF CONCERN OR QUALIFYING AREA IF A RE-EVALUATION by someone other

than the child’s regular teacher.

OBSERVER: ________________________________________ TEACHER: _______________________________________

□ English/LA □ Math □ Reading ____ Number of Students

CLASSROOM ARRANGEMENT:

□ Rows □ Grouped desks □ Tables □ Other

________________________________________

CLASSROOM ACTIVITY/LESSON OBSERVED:

__________________________________________________________________

______________________________________________________________________________________________________

Observation should not occur during review/test taking or independent work.

INDICATE METHODS OF INSTRUCTION USED DURING OBSERVATION:

□ Lecture/Note Taking □ Group Investigation □ Drill & Practice□ STAAR Practice □ Learning Centers □ Discussion□ Lab Training □ Discovery □ Peer Tutoring□ Independent Study □ Role Playing □ Other __________________ THE FOLLOWING ACCOMMODATIONS WERE USED DURING THE OBSERVATION:

□ Para/Aide Assistance □ Assignment Notebook □Preferential Seating□ Oral Testing/Reading Assist. □ Shortened Assignment □Provide Copies of Material□ Repeating Directions □ Additional Time □Copies of Notes from another student□ Use of Calculator □ Study Guide □Peer Tutoring□ Charts/Manipulatives/Graphic Organ. □ Extra Grade Credit □ Behavior/Performance Contract□ Modified Grading □ Compacting/Chunking □ Highlighted Textbook/Notes□ Modified Format □ Other ______________________________________________________BEHAVIORS THAT IMPACT LEARNING: YES NO

Attends to task ___ ___Follows oral directions ___ ___Participates in class discussions ___ ___ How many times during observations? #_________ ___ ___Was the student redirected for attention? ___ ___ How many times during observation? #_________ ___ ___

Requires excessive teacher support ___ ___Organized approach to materials/assignments ___ ___Comes to class prepared ___ ___Cooperates/Complies with teacher requests ___ ___Interacts appropriately with peers ___ ___ ADDITIONAL INFORMATION YOU FEEL IS RELEVANT TO THE

OBSERVATION:_________________________________________

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Tier 3-EXCLUSIONARY FACTORS WORKSHEETStudent Name: _____________________________ Grade: ______ Completed by: _________________________________ Date: _________

In determining special education eligibility, the group of qualified professions must ensure that the identified area of concern is not primarily the result of one of the following. As you work through the flowchart, keep the student's area of concern in mind and consider individual characteristics of the student as you answer

YES or No to each question.

Is the student’s lack of sufficient progress dueprimarily to cultural factors? (Is the student background different from school/society?

No Yes

Is the student’s lack of progress due primarily to economic or environmental disadvantage? (major home responsibilities, caring for sibling while parents are at work, etc.)

No Yes

Is the student’s lack of progress due primarily to limited English proficiency?

No Yes

Do attendance patterns show that the student has changed schools often or that student attendance patterns have affected normal achievement gains?

No Yes

Have there been any significant or traumatic events in the student’s life that contribute to the lack of progress?

No Yes

Are there any variables related to family history that may have affected school performance? (removal from biological family/siblings, length of residence in the US, stress, etc)

No Yes

Are there any variables in the student’s medical history that may have affected school performance? (illness, trauma, or injury, nutrition)

No Yes

Is the student’s lack of sufficient progress due primarily to an intellectual disability, emotional disturbance or hearing/vision/motor disability? (use hearing/vision screening form, previous evaluation, etc. for documentation)

If all answers are “NO”, the student MAY BE CONSIDERED for special ***If any answer is “YES” the student CANNOT be education services. found eligible for special education services.

Documents

€¦ · Web viewFidelity of implementation is the delivery of instruction in the way in which it was designed to be delivered and researched to be effective (Gresham, MacMillan,