Web view(may be low incidence equipment or assistive technology device): ... Medication for ADD/ADHD or other behaviors. Difficulty to participate in large group

NAPA COUNTY SELPA SPECIAL CIRCUMSTANCE INSTRUCTIONAL

ASSISTANCE (SCIA)

Pre-ReferralActivities Review

STEP 1

Required prior to completion of SCIA packet. Send this review

to your Special Education Director.

______________________Student’s Name

______________________Teacher

______________________School

______________________ Email Phone

Pre-Referral ActivitiesChecklist of Environmental Supports

Student Name: ________________________________CA: _________________ Birth date: ___/___/___

School: ______________________________________Grade:____________ Date: ___/___/___

Prepared by Teacher: _________ Psych./Prog. Specialist: _________________

A.Classroom Schedule: Suggestions/Next StepsIs there a posted classroom schedule?YES (answer questions below) NO

1. The following elements are included in the classroom schedule: times students activities locations staff names

2. The schedule is: daily weekly other

*Attach sample classroom scheduleB. Schedule for individual student: Suggestions/Next Steps

Is there an individual student schedule?YES (answer questions below) NO

1. Student uses the following format for individualized schedule: object icon photograph word picture planner computerized homework assignment

2. Student ability to follow the schedule: independent with physical prompts with indirect verbal inconsistent with direct verbal prompts

3. Student use of schedule: student carries schedule student uses transition cards student goes to scheduled board inconsistent teacher carries and shows the schedule

4. Room is arranged with structure to correlate with tasks on schedule (check all that apply):

areas for one-to-one work area for independent work area for group work area for leisure

not applicable *Attach sample classroom schedule

REQUIRED DOCUMENT PRIOR TO COMPLETION OF SCIA PACKET. DISTRICT: SEND THIS PORTION TO THEIR SCIA ADMINISTRATOR. COUNTY: TURN INTO MANAGER**SEE DISTRICT AUTHORIZATION PAGE FOR NEXT STEPS

C.Curriculum and instruction:1. Are materials and activities differentiated for student’s:

Chronological age? (describe)

Ability level? (describe)

Interest level? (describe)

2. Check the curricular domains included in the student’s program: communication with physical prompts self-care domestic skills inconsistent academics motor skills/mobility other:______________

List equipment or devices used/available that may relate to the need for assistance (may be low incidence equipment or assistive technology device):

Describe an activity which is challenging for the student. If appropriate, attach a sample task analysis form used for a challenging activity with the student (see page 20 for sample form):

Suggestions/Next Steps

D.Behavior Support:Are there problem behavior(s) interfering with learning of self or others?YES (answer questions below) NO

Brief description of problem behavior(s)

Where behaviors typically occur (list 3 behaviors)

When behaviors typically occur (list 3 behaviors)

1. Student has a Positive Behavior Support Plan/Behavior Intervention Plan:YES (answer questions below) NO

2. How effective is the plan in addressing the student’s needs? Very Moderately Mildly Not at All

3. Describe anticipated level of support to implement plan (i.e., frequency of reinforcement, prompting, redirection):

4. What supports exist for implementing the plan? (i.e., self-monitoring, other adults):


*Attach Behavior Support Plan/Behavior Intervention Plan

E. Current data systems and collection of data:Are there current data on each IEP objective and/or behavior plan?YES (answer questions below) NO

1. Data records include: date level of independence (prompting needed) task level of progress

2. Data are collected: daily other:________________ weekly amount of time data collected (determined by dist.) monthly number of settings data collected (determined by dist.)

3. Data are summarized: graphed other:______________ written narrative

*Attach sample data collection sheet-sample form on page 19.


F. Planning team meetings:Are team meetings held? (formal or informal meetings to problem solve):YES (answer questions below) NO

1. Meetings are held: daily weekly bi-weekly monthly needed not applicable

2. Meetings include: parent(s) specialists special education teacher general education teacher yard duty other:___________

*Attach team meeting format.


G. Explanation of settings where supports may be needed (classroom, playground, lunch room, passing times, locker room).

Existing accommodations/modifications:

Diagram or describe the arrangement of furniture, small group instruction areas, and/or equipment of the classroom or other setting:

*Attach diagram (optional)


H. Check and describe other supports currently provided: Dates:

training for instructional staff________________ ____________ consultation for the classroom staff_____________ ____________ in-classroom coaching________________ ____________ other_________________ ____________


I. Describe Health related issues:

Seizures Average per day at school_____ per week at school_____ Duration of each seizure_________ petit mal____ grand mal_____ Other types of seizures__________________________________________ # of classroom staff trained______________________________________ Date of last seizure at school_____________________________________

Diabetes Type: _________________________________________ Insulin dependent? Yes No Describe procedure done by staff:_________________________________ _____________________________________________________________ _____________________________________________________________ Length of time for procedures:____________________________________

Other health related issues:____________________________________ ____________________________________________________________ ____________________________________________________________ # of classroom staff trained______________________________________

g-tube feeding # of classroom staff trained___________________

Other procedures____________________________________________ # of classroom staff trained_______________________________________

Other procedures____________________________________________ # of classroom staff trained_______________________________________


Please summarize from this form components that need to be developed/implemented and/or where further training/consultation/coaching may be needed before considering need for additional adult support (see notes in “suggestions/next steps” column).

PRE-REFERRAL ACTIVITIES REVIEW REQUIRED

THE DISTRICT ADMINISTRATOR NEEDS TO AUTHORIZE THE CONTINUATION OF THE SCIA PACKET AFTER THE REVIEW OF THE PRE-REFERRAL ACTIVITIES CHECKLIST

Student Name: _________________________________________________ Grade: ______________________

School: _____________________________________CA:_______________ Birth date: _____/_____/______

Teacher: _____________________________________________________________________

District SCIA Administrator/County Manager: ___________________________________________________

Review Date: _____/_____/_____

______ Continue with SCIA packet

______ See suggestions/next steps in order to continue with SCIA packet. You must re-submit “Pre-Referral Activities” checklist with added suggestions/next steps.

See suggestions/next steps on actual “Pre-Referral Activities” checklist OR see comments below:

District Administrator Signature ____________________________ Date_______

NAPA COUNTY SELPA SPECIAL CIRCUMSTANCE INSTRUCTIONAL ASSISTANCE

(SCIA)

STEP 2

Pre-Referral Activities Review, (Step 1), must be completed and approved by SCIA

Coordinator before proceeding to Step 2

________________________Student’s Name

______________________Teacher

_______New Authorization ______Re-Authorization

______________________Date

SCIA REQUIRED DOCUMENTATIONBY AREA OF NEED

Student Name: _____________________________CA: _________________ Birth date: _____/_____/_____

School: ___________________________________Grade: ______________ Date: _____/_____/_____

Pre-Referral Activities Checklist Completed (Initial Referral Only)

HEALTH BEHAVIOR

Required

SCIA Rubric – All 4 sections Student Schedule Health Records Specialized health care plan School Day Analysis (use Health form)

Required

SCIA Rubric – All 4 sections Student Schedule Psycho-Educational Reports Goals: Progress Reports Academic progress assessments * Behavior Support/Intervention Plan Review BSP/BIP Behavioral Data Discipline Referrals School Day Analysis

*Optional

INSTRUCTION INCLUSION (Social interaction)

Required

SCIA Rubric – All 4 sections Student Schedule Psycho-Educational Reports Goals: Progress Reports Academic progress assessments School Day Analysis

Required

SCIA Rubric – All 4 sections Student Schedule Psycho-Educational Reports Goals: Progress Reports Academic progress assessments Behavior Support/Intervention Plan Review BSP/BIP Behavioral Data Discipline Referrals Health Records School Day Analysis

Date:

Initial Re-Authorization

Napa County SELPASummary of Evaluation for Additional Support

Student: _____________________ District: __________________DOB: ___/___/___

Age: _______ Male Female Grade Level: __________ School: ________________

Check the areas of intensive need that might indicate additional instructional assistant support.

Health/Personal Care

Behavior Instruction Inclusion/Mainstreaming

Specialized health plan

G-tube

Medications

Suctioning

Food preparation

Diaper changing

Feeding-full support

Seizures weekly

Lifting/Transfers

Other:____________

Behavior plan in place

Physically aggressive daily weekly

Non-compliant in class

Runs away daily

Runs away weekly

ADHD medicated

Mental health client

Other:___________

Discrete Trial/ABA

Physical prompts 80%+

Verbal prompts 80%+

Structured teaching

Assistive technology

PECs

Signing 80%+

Other:_________

Direct adult instruction

Physical positioning /support

Safety supervision 80%+

Close visual supervision 80%+

Adult required for socialization

Other:______________

Date:____________

Describe EACH area of intensive need marked above and indicate if there is an IEP goal/objective written to address the area. Use additional paper if needed to describe all needs.

Describe interventions used to support referred student in EACH of the areas marked above. Provide data that documents the prior success or failure of interventions and complete attached rubric. Include a school day description and description of assistance needed.

Student Needs for Additional Support Rubric

Student Name: DOB: Disability: Date Reviewed: Case Manager: School: District:

Select the number that best describes the student in each rubric category that is appropriate.Health/Personal Care/Rating Behavior/Rating Instruction/Rating Inclusion/Mainstreaming/Rating

0

General good health. No specialized health care procedure, medications taken, or time for health care. Independently maintains all “age appropriate” personal care.

Follows adult directions without frequent prompts or close supervision. Handles change and redirection. Usually gets along with peers and adults. Seeks out friends.

Participates fully in whole class instruction. Stays on task during typical instruction activity. Follows direction with few to no additional prompts.

Participates in some core curriculum within general education class and requires few modifications. Can find classroom. Usually socializes well with peers.

1

Mild or occasional health concerns. Allergies or other chronic health conditions. No specialized health care procedure. Medications administration takes less than 10 minutes time. Needs reminders to complete “age appropriate” personal care activities.

Follows adult directions but occasionally requires additional prompts. Occasional difficulty with peers or adults. Does not always seek out friends but plays if invited.

Participates in groups at instructional level but may require additional prompts, cues, or reinforcement. Requires reminders to stay on task, follow directions and to remain engaged in learning.

Participates with modification and accommodation. Needs occasional reminders of room and schedule. Requires some additional support to finish work and be responsible. Needs some social cueing to interact with peers appropriately.

2

Chronic health issues, generic specialized health care procedure. Takes medication. Health care intervention for 10-15 minutes daily (diet, blood sugar, medication). Requires reminders and additional prompts or limited hands on assistance for washing hands, using bathroom, wiping mouth, shoes, buttons, zippers, etc. Occasional toileting accidents.

Has problems following directions and behaving appropriately. Can be managed adequately with a classroom behavior management plan, but unable to experience much success without an individual behavior chart, checklist and behavior goal.

Cannot always participate in whole class instruction. Requires smaller groups and frequent verbal prompts, cues, or reinforcement. On task about 50% of the time with support. Requires more verbal prompts to follow directions.

Participate with visual supervision and occasional verbal prompts. Requires visual shadowing to get to class. Needs modifications and modifications to benefit from class activities. Regular socialization may require adult facilitation.

3*

Very specialized health care procedure and medication. Limited mobility. Physical limitations requiring assistance (stander, walker, gait trainer or wheelchair). Special food preparation or feeding. Health related interventions 15-45 minutes daily. Frequent physical prompts and direction assistance for personal care. Food preparation required regularly. Requires toilet schedule, training, direct help, diapering.

Has behavior problems almost daily. Defiant and/or prompt to physical aggression. Requires a Behavior Support Plan (BSP) and behavior goals and objectives on the IEP. Requires close visual supervision to implement BIP. Medication for ADD/ADHD or other behaviors.

Difficulty to participate in large group. Requires los student staff ration, close adult proximity and prompts including physical assistance to stay on task. Primarily complies only with SCIA directions and monitoring. Cognitive abilities and skills likely require modifications not typical for class as a whole. Needs Discrete Trial, ABA, Structured Teaching, PECS. Requires signing over 80% of the time.

Participation may require additional staff for direction instruction and behavioral support. Requires direct supervision going to and from class. Always requires modifications and accommodations for class work. Requires adult to facilitate social interaction with peers.

4* Specialized health care procedure requiring care by specially trained employee (G tube, tracheotomy, cautherization). Takes medication, requires positioning or bracing multiple times daily. Health related interventions 45 minutes daily. Direct assistance with most personal care. Requires

Serious behavior problems with potential for injury to self and others, runs away, aggressive on a daily basis. Functional Analysis of Behavior (FAA) or Hughes Bill has been completed and the student has a well-developed BIP, which must be implemented to allow the student to safely attend school.

Cannot participate in group without SCIA support. Requires constant verbal and physical prompting to stay on task and follow directions. Regularly requires specific 1:1 instructional strategies to benefit from the IEP. Cognitive abilities and skills require significant accommodation and

Always requires 1:1 staff in close proximity for direct instruction, safety, mobility or behavior monitoring. Requires SCIA assistance to go to and from class 80% of the time. Requires adult to facilitate social interaction with peers and remain in close proximity at all time.

Student Needs for Additional Support Rubrictwo-person lift. Direct SCIA assistance 45 or more minutes daily.

Staff has been trained in the management of assaultive behaviors (NCPI, ProAct, etc.)

modification not typical for the class group.

Attach a copy of documentation indicating frequency and duration over a period of time to determine further consideration of special circumstance instructional assistance. If mostly ratings of 3’s

& 4’s in to or more areas, continue with needs assessment process.

NAPA COUNTY SELPA SCHOOL DAY ANALYSISOver 3 observations, over 3 days in 3 different settings

Student: DOB: Disability:

Case Manager: Psych./Program.Specialist:/Other (state title) Program/School:

Completed by: Title:

Time(15 minute increments)

Activity* (Min. of 3 different settings to include structured/

unstructured activities)

What student can do without assistance

What student needs accommodation/

assistance to complete

What adults support is currently available (specify and include ratio)

Can peer support be provided

(specify)

Is there, or can there be, an IEP goal for

independence (specify)

Medical procedures (indicate by nurse or

paraeducator)

Date:_____/______/______

Date:_____/______/______

Date:_____/______/______

NAPA COUNTY SELPA SCHOOL DAY ANALYSISOver 3 observations, over 3 days in 3 different settings

Student: DOB: Disability:

Case Manager: Psych./Prog. Specialist:

Completed by: Title:

Time(15 minute increments) Activity

What student can do without assistance

What student needs accommodation/

assistance to complete

What adults support is currently

available (specify and include ratio)

Can peer support be provided

(specify)

Is there, or can there be, an IEP goal

for independence (specify)

Medical procedures (indicate by nurse or

paraeducator)

Date:_____/______/

______

Date:_____/______/

______

Date:_____/______/

______

HEALTH ONLY

Draft IEP Goal for SCIA OR attach existing IEP goal that addresses needTarget Behavior :

Describe the behavior of the student that you want to increase/decrease:

Describe the current frequency of the behavior, including times of day and circumstances when the behavior occurs:

Criteria for fading SCIA:

Develop a draft IEP goal and benchmarks for progress reportingArea of Need:

Baseline:

Measurable Annual Goal:

Short term objective:



Reviewed:___________________ Approved:_____________________ Date:_____________

Review the Success of SCIA Support

Student Name _______________________________________ DOB____________

School______________________________________________Grade___________

Teacher_____________________________________________Room___________

What worked? What didn’t work?

What contributed to the success of the student? What impeded the success?

What needs to happen next? Comments:

Please Print:

LEA Representative _______________________________________ Date _______________

Teacher___________________________________________________________ Date _______________

NAPA COUNTY SELPA

SPECIAL CIRCUMSTANCE INSTRUCTIONAL ASSISTANCE (SCIA)

Student Name: _________________________________________________ Grade: __________________

School: _____________________________________CA:________________ Birth date: ____/____/____

Teacher: ______________________________________________________________

District SCIA Administrator/County Manager: ______________________________________________

_______ APPROVED

_______ SENT TO HR DEPARTMENT (DISTRICT)

DATE: ____________________________

_______ NOT APPROVED

_______ SENT BACK TO CASE MANAGER

DATE: ____________________________

11/3/16

Documents

Web view(may be low incidence equipment or assistive technology device): ... Medication for ADD/ADHD or other behaviors. Difficulty to participate in large group