SAT/RTI Initial Paperwork Checklist

Transcription

1 SAT/RTI Initial Paperwork Checklist Before turning packet in to principal to begin SAT/RTI process, all must be attached: _ Pink parent forms _ Blue teacher forms _ NWEA printed scores _ NeSA scores (if available) _ DIBELS printed scores _ Title 1 Needs Assessment (if available)

2 SAT/RTI Flow Chart Form Color: Orange Teacher Concerned: Implement Classroom Interventions Initial Parent Contact Made Student Making Progress Do not refer to SAT/RTI Student NOT making Progress Refer to SAT/RTI Teachers: Complete Teacher Input Forms I & II Parents: Complete Developmental Checklist & Permission Forms & Given SAT/RTI Pamphlet Initial SAT/RTI Team Mtg. Develop Intervention Plan Date Begin Implementing Intervention Plan *Monitor Progress of Student SAT/RTI Meeting to Review Progress (Intervention Plan Follow Up) Date Student Making Progress Continue with Intervention Plan Complete New Intervention Plan Date Student NOT Making Progress Implement Intervention Plan *Monitor Progress of Student SAT/RTI Meeting to Review Progress Date Student Making Progress Continue with Intervention Plan Complete New Intervention Plan Date Student NOT Making Progress Implement Intervention Plan *Monitor Progress of Student SAT/RTI Meeting to Review Progress (Intervention Plan Follow Up) Date Student Making Progress Student NOT Making Progress Continue with Intervention Plan Refer for Special Education Testing Date Student Qualifies for Special Education Student does NOT Qualify for Special Education Create IEP Refer back to SAT/RTI Create Intervention Plan

3 SAT/RTI Flow Chart Form Color: Orange Parent Request for Testing Refer to SAT/RTI Teachers: Complete Teacher Input Forms I & II Parents: Complete Developmental Checklist & Permission Forms & Given SAT/RTI Pamphlet Initial SAT/RTI Team Mtg. with Parents Develop Intervention Plan Date Begin Implementing Intervention Plan *Monitor Progress of Student SAT/RTI Meeting to Review Progress Date Report Results to Parents Student Making Progress Continue with Intervention Plan Complete New Intervention Plan Date Student NOT Making Progress Implement Intervention Plan *Monitor Progress of Student SAT/RTI Meeting to Review Progress (Intervention Plan Follow Up) Date Report Results to Parents Student Making Progress Continue with Intervention Plan Student NOT Making Progress Refer for Special Education Testing Date Student Qualifies for Special Education Student does NOT Qualify for Special Education Create IEP Refer back to SAT/RTI Create Intervention Plan

4 SAT/RTI Teacher Information Form Form Color: Blue Student Name: School: Classroom Teacher: Date: Reading Teacher: Please complete this information form on the student listed above. Feel free to write 1. Is this student receiving Title One Services? 2. Does this student currently have an IEP? 3. Does this student currently have a 504 plan? 4. Has the SCIP process ever been implemented for this student? additional comments and/or impressions regarding this student. Subject Areas: Current Grade Test Grade % Assignments Handed In Quality of Work Poor Improving Adequate Good Excellent Poor Improving Adequate Good Excellent Poor Improving Adequate Good Excellent Poor Improving Adequate Good Excellent Poor Improving Adequate Good Excellent Strengths: Academic Concerns (please check all that apply): Basic Reading Skills Reading Fluency Reading Comprehension Vocabulary Memorization Skills Spelling Writing Math Calculation Story Problems Following Assignment Directions Other(s): Behavior Concerns (please check all that apply): Attention Attendance Asking Questions Aggression Anxiety Hyperactivity Impulsiveness Depression Participation Self-Harm Bullying Tiredness Suicide Ideation Following Directions Following Rules Study Skills Work Completion Tardiness Organization Withdrawal Other(s): Social Concerns (please check all that apply): Social Skills Peer Relations Social Interactions Eye Contact Rigidness to Routines Emotional Awareness Physical Proximity Limited Interests Unable to read Social Cues Difficulty with Transition Unable to read Facial Expressions SCIP Evaluation Current SCIP Evaluation Previous Other(s): Motor Concerns (please check all that apply): Fine Motor Gross Motor Handwriting Speech/ Language Concerns: Please complete Speech/ Articulation and Fluency Forms. Additional Comments/ Information: Please use the back of this form Page 1 of 2

5 SAT/RTI Teacher Information Form #1 Language Concerns Form Color: Blue Mark which areas the student exhibits difficulties: Math Language Arts Basic Concepts Comprehension of Written Information Comprehension of Directions Comprehension of Oral Information Short Term Recall Asking Questions Answering Questions Main Ideas/Details Fact/Opinion Predicting/Inferring Multiple Meaning Words Phonemic Awareness Organization Organization and Editing of Written Work Vocabulary Figurative Language Sequencing Participation in Class Discussion Topic Maintenance Turn Taking Simplified Sentence Structure Word Retrieval Non Specific Language Social Studies/ Science Specials Non- Academic Times Page 2 of 2

6 SAT/RTI Teacher Information Form #2 Form Color: Blue Green Yellow Student s Name Grade Teacher s Name Primary Concern: Please indicate all strategies that have already been implemented READING/ COMPREHENSION Start Date Whole Group Small Group One-on-One Amt. of Time (minutes per day) Documentation Exists Additional Phonics Direct Instruction Repeated Reading Repeated Listening Tapping Preview/Listen/Practice/ Paired Reading Chunk Strategy Additional Letter Identification Sound to Work (a apple /a/) Choral Responding Story Map Use of Visual Aids/ Pictures Multi-Step Text Review Whisper Phones Fluency Builders Vocabulary Games/Activities Vocabulary Builders Graphic Organizers (Main Idea; Elements of Literature) Breaking Tasks Down into Smaller Parts Continued on the back Page 1 of 2

7 MATH Cover/Copy/Compare Math Manipulatives Highlight the Operation to be performed Breaking Tasks Down into Smaller Parts Use of Visual Aids/ Pictures Flash cards Number Line Math In a Flash Touch Math Start Date Whole Group Small Group One-on- One Amt. of Time (minutes per day) Form Color: Blue Green Yellow Documentation Exists WRITING/ SPELLING Handwriting Without Tears Write- Say Method Multi- Sensory (writing in Jell- o, sand, etc) Graphic Organizer Idea Mapping Breaking Tasks Down into Smaller Parts Start Date Whole Group Small Group One-on- One Amt. of Time (minutes per day) Documentation Exists BEHAVIOR/ ORGANIZATION Giving Breaks Use of a Timer Having Student Repeat Directions Assignment Book Breaking Tasks Down into Smaller Parts Rewards Teacher Proximity Praise Use of Checklists or Picture Schedule Time Out Use of Visual Aids/ Pictures Behavior Plan Start Date Whole Group Small Group One-on- One Amt. of Time (minutes per day) Documentation Exists Page 2 of 2

8 Parent Form Developmental History Information Form Color: Pink I. Student Information: Student Name: DOB: / / Grade: Teacher: School: Parent(s)/ Guardian: Address: Phone: What is your preferred method of communication? Phone Regular Mail II. Family Information: What are your child s strengths? What concerns do you have for your child? In what language did your child first learn to talk? If English is 2nd language, how long has your child spoken English? What language is primarily spoken at home? Major Life Events Experienced by Your Child: Divorce of Parents Death of a Close Family Member Major Illness Home Dislocation Home Fire Natural Disaster Is there any other major life event experienced by your child that you think may have had an impact on your child: III. Medical History: Child s physician Physician phone # Check any of the following complications that occurred during the pregnancy: Toxemia Gestational Diabetes Measles RH incompatibility Alcohol Tobacco Low Oxygen Premature Birth Other Has this child ever had any serious illnesses, accidents, or head injuries? Yes No If yes, please explain: Has this child ever experienced problems in the following areas? walking temper tantrums underweight/ overweight unclear speech failure to thrive hearing vision sleep problems eating problems does not speak fine motor skills (handwriting, tying shoes, etc) Difficulty making friends gross motor skills (running, riding bike, skip, etc) Other If any of the above are checked please specify: Please indicate any illness this child has experienced: Measles Mumps Asthma Frequent Ear Infections Gastro-intestinal problems Diphtheria Seizures Rheumatic fever Loss of consciousness Any heart condition Meningitis Allergies Verbal/ motor tics Other, please describe:

9 Form Color: Pink Is this child presently on any medications? Yes No If yes, what kind? Has your child ever had psychological counseling or therapy? Yes No Complete the following if Yes : Counselor s Name: Phone: Has this child ever had a neurological exam? Yes No If Yes, please specify: IV. Educational Background: Did this child attend preschool? Yes No If Yes, where and for how long? Have any relatives had difficulties similar to those this child is experiencing? Yes No If Yes, please explain: Please indicate whether this child exhibits any of the following behavior: Has a short attention span Has Fears Overreacts when faced with a problem Unhappy much of the time Seems impulsive Requires a lot of attention Enjoys active games Enjoys activities such as reading, drawing, writing, etc. Needs more help with school work than others his/her age Other: Please indicate any of the following that this student has experienced in school: Skipped a grade Disliked going to school Had frequent absences from school Behavior problems Emotional difficulties Poor Grades Been Retained Difficulty with Reading Difficulty with Math Difficulty with writing or spelling Changed schools several times in one school year Has been evaluated for special education Other: V. Social History: How does your child spend his/her free time? How may close friends does your child have? or more Please indicate if your child is able to do the following [now or earlier in their development]: Show good eye contact Engage in pretend play Discuss a variety of interests Initiate conversation Initiate play Is able to adjust to changes in routine Signature of person completing this form: Relationship to the student: Please return this form to:

10 SAT/RTI Permission for Specialist s Participation Form Color: Pink Student Name The Student Assistance Team / Response to Intervention Team requests parental permission for an Educational Specialist (E.g. School Psychologist, Speech Pathologist, Vision Specialist, Occupational Therapist, and/or Physical Therapist) to be involved in the informal assessment for the above named student. Informal assessments may include: Observations, interviews, checklists, brief assessments or curriculum based measurements, or other data collection. I give permission and I understand this consent is voluntary and may be revoked at any time. I do not give permission Parent Signature Date Note: This permission is not for a special education or Section 504 evaluation. However, the informal screening may contribute to a SAT/RTI team decision to refer for such services.

11 Form Color: Green Intervention Plan Date: Student s Name SAT/RTI Team Leader Present Level of Performance: This student currently A typical peer currently Discussion Points: What CHILD CHARACTERISTICS might be related to the concern? What CURRICULUM issues might be related to the concern? What PEER issues might be related to the concern? What CLASSROOM ENVIRONMENT issues might be related to the concern? What HOME/COMMUNITY issues might be related to the concern? What TEACHER issues might be related to the concern? INTERVENTION/S: (You must have at least 1 researched base intervention & time NEEDS to be additional to the CORE) Materials Needed Times per Length of Time Week: per Session: (ex. Sound Partners) 1. (ex. Sound Partners Program) (ex. 5) (ex. 60 minutes) Person(s) Responsible for Intervention (ex. John Doe) Page 1 of 2

12 Form Color: Green GOAL/PROGRESS MONITORING: Monitoring will occur more often Baseline Goal How Often (times per week/month) Target Date Person(s) Responsible for Progress Monitoring (ex. DIBELS) 1. (ex. 1 X per week for a total of 8 Data Points) (ex. Jane Doe) The following individuals attended this meeting: Next SAT/RTI meeting scheduled for: at Page 2 of 2

13 Form Color: Yellow DATE: Intervention Plan Follow Up Student s Name SAT/RTI Team Leader MONITORING TOOL BASELINE GOAL CURRENT DATA Has the problem changed since the last meeting? YES NO Was the Intervention plan carried out as written? YES NO If no, please explain According to your progress monitoring data and documentation, is the Intervention Plan working? YES NO If yes, continue with Intervention plan and DO NOT revise the plan and skip to signatures. If no, revise the intervention plan and reconvene at a later date: REVISED INTERVENTION PLAN: Materials Needed Times per Week: Length of Time per Session: Person(s) Responsible for Intervention (ex. Early Reading Intervention) (ex. Scott F s ERI Kit) (ex. 5) (ex. 30 minutes) (ex. John Doe) GOAL/PROGRESS MONITORING: Monitoring will occur more often Baseline Goal How Often (times per week/month) Target Date Person(s) Responsible for Progress Monitoring (ex. DIBELS) (ex. 1 X per week for a total of 8 Data Points) (ex. Jane Doe) The following individuals attended this meeting: Next SAT/RTI meeting scheduled for: at

14 Form Color: Gold Date: Review of Intervention Plan/SPED Referral Student s Name: GOAL/PROGRESS MONITORING: MONITORING TOOL BASELINE GOAL CURRENT DATA Has the problem changed since the last meeting? YES NO If YES, redefine the problem: Were the Interventions carried out as written? YES NO If no, please explain According to your progress monitoring data and documentation, are the Intervention Plans working? YES NO If yes, continue with Intervention plan and DO NOT refer for Special Education Testing. Schedule another date to reconvene and monitor plan/ progress. If No, complete the information below: 1. Does the response to general education interventions indicate the need for intense instruction in order for the student to make progress in the area(s) of concern? 2. Does there appear to be evidence of a severe discrepancy between the performance of the student and his/her peers, or evidence of a severe discrepancy between the student s ability and performance? 3. Are the educational resources needed to support the student in the area(s) of concern beyond those available through general education resources? The SAT/RTI requests more information be obtained regarding to determine special education eligibility. Please indicate the information requested: Intellectual/ Ability Academic Social/ Emotional Behavioral ADD/ADHD Articulation Language Motor (fine or gross) Vision Hearing Autism Spectrum The following individuals attended this meeting: SAT/RTI materials submitted to Director of Special Services by on (Principal) date

15 Form Color: Orange SAT/RTI Process for Articulation and Fluency only 1. Teacher makes referral to SAT/RTI. 2. The following forms need to be completed: a. Teacher Referral b. Parent Information sheet 3. Once SAT/RTI coordinator receives forms, notify SLP. 4. SLP will complete an observation of the child. 5. SAT/RTI meeting occurs. 6. SLP will then send permission to test.

16 Form Color: Blue SAT/RTI Teacher Referral Sheet Speech Only (Articulation and Fluency) Date: 1. Student Information Name Date of Birth Grade Parent/Guardian Teacher/School 2. Teacher Concern (describe & give examples) a. articulation b. stuttering c. vocal quality d. hearing 3. How does this impact student s classroom performance? Parent Contacted Date: Method of Contact: Teacher Signature Date

17 SAT/RTI Form Color: Pink 1. Student Information Parent Input Sheet Speech Only (Articulation and Fluency) Date Name Date of Birth Grade Parent/Guardian Address City/State/Zip Home Phone Teacher/School 2. Medical History (ear infections, tonsils, hearing, allergies, medications) 3. Parental Concerns The Speech Language Pathologist (SLP) has permission to observe my child in the educational setting, if needed. Signature Date 8/2011

18 Student Intervention Person Administering Intervention Intervention Fidelity Log Form Color: Green Yellow Date #### What was the lesson? Session length? Student on task? #24--two letter combos 20 min y/n Progress Monitored? Score? Comments.. yes-nwf 28 Johnny left early. y/n y/n y/n y/n y/n y/n y/n y/n y/n