Checklist Student: SSID#: Date: Age: Grade: Disability: DOB: Gen Ed Teacher: Placement: School: Sp Ed Teacher: Contact Phone: SCIA Case Manager: I. Interventions Previously Implemented To Be Completed by IEP Case Manager/Psychologist Prior to Referral Prior to considering a SCIA referral, team must exhaust all existing and natural supports contained in the IEP and Intervention Plan (BIP) Gather al Data (data collection on frequency, duration, and severity) Review BIP implementation data, if appropriate BIP Data and strategies used to increase replacement behaviors; implementation for at least three months with revisions, as needed Gather information from other records, as appropriate Academic Progress/Interventions and behavioral data Student s Schedule (including grades and attendance) Psycho-Educational Report(s) (initials) Discipline Referral Information (initials) Health Records (initials) Communication Competency (initials) Use of AT/AAC (initials) (initials) (initials) II. Referral Process Step 1 To Be Completed by School Site Staff/IEP Case Manager Complete SCIA Rubric (Step 1 Form 1) Complete Review of BIP and progress on behavior goals (Step 1 Form 2) Complete SCIA Referral (Step 1 Form 3) III. Assessment Process To Be Completed by IEP Case Manager and/or SCIA Case Manager Step 2 Step 3 Complete and Send Notice of Proposed Action and Evaluation Plan Obtain Parent Permission to Evaluate Complete SCIA Parent Interview(s) (Step 3 Form 1) Complete SCIA Teacher Interview(s) (Step 3 Form 2) Complete SCIA Student Interview, as appropriate (Step 3 Form 3) 1 of 22
Step 4 Step 5 Complete SCIA Observation: Environmental Considerations (Step 4 Form 1) Complete SCIA Classroom Observation of Student (Step 4 Form 2) Complete additional Evaluation(s) per Assessment Plan Develop SCIA Evaluation Report and Independence Plan (Step 5 Form 1) IV. IEP Process Step 6 Hold IEP Meeting to review results of Evaluation If SCI support IS NOT recommended Specify natural supports, accommodations, and/or modifications that are effective in student s IEP Add IEP goals and objectives, if appropriate Revise BIP, if necessary If SCI support IS recommended Identify IEP Goals and Objectives to be supported by SCI support Complete IEP Special Factors page regarding, if appropriate Complete IEP Services page: under Supplementary Aids, Services and Supports for School Personnel Check: Intensive Individual Services Include start/end date, frequency and duration, and location of SCI support Review proposed Independence/Fading Plan (Step 5 From 1, Section V.) and type of documentation that will be collected Set review date within 3 to 6 months to assess continued need of SCI support Follow district procedures for hiring staff If parent(s) are not in agreement, complete and send Prior Written Notice to parents V. SCIA Review Step 7 Select IEP date to review progress on independence goals Conduct on-going observation, necessary interview, and progress towards independence Review BIP Analyze and revise, as needed Complete SCIA Review to Determine Continued Need for Special Circumstance Independence (SCI) Supports (Step 7 Form 1) Review Independence/Fading Plan (Step 5 From 1, Section V.) and documentation with parent and IEP team Items in BOLD are SCIA forms; Forms not in bold are regular district/selpa forms. 2 of 22
Rubric Student Name DOB Disability Date Reviewed Teacher Current Program Person Completing Rubric (Name/Title) CHECK THE BOX that best describes the student in each rubric category, as appropriate. /Rating /Rating /Rating Least Restrictive Environment Independently maintains all age appropriate personal care and/or medical needs. Independently addresses own behavior needs. Required behavior supports are similar to those of same aged peers. Independently participates fully in whole class instruction. Stays on task during typical instruction activity with the same level of prompting as peers in the classroom. Participates in core curriculum within general education class and requires few modifications. Requires support with 0-25% of their age appropriate personal care and/or medical needs. Requires adult assistance for 0-25%- of the day to address behavior needs described in BIP. Requires prompts to stay on task, follow directions and to remain engaged in learning 0-25% of the time. Requires prompts to participate in general education and/or interact with peers 0-25% of the time. Requires support with 26-50% of their age appropriate personal care and/or medical needs. Requires adult support for 26-50% of the day to address behavior needs described in BIP. Requires prompts and adult support 26-50% of the time to participate in whole class instruction, receive reinforcement, and follow directions. Requires prompts to participate in general education and/or interact with peers 26-50% of the time. Requires support with 51-75% of their age appropriate personal care and/or medical needs. Requires adult support for 51%-75% of the day to address behavior needs described in BIP. Requires low student staff ratio, close adult proximity and prompts including physical assistance to stay on task 51-75% of the time. Requires prompts to participate in general education and/or interact with peers 51-75% of the time. Direct support with at least 76% or all personal care and medical needs Examples include: specialized health care procedure requiring care by specially trained employee (G- tube, tracheotomy, catheterization); medication administration requires positioning or bracing multiple times daily. Requires two-person lift. Requires adult support for 76%-100% of the day to address behavior needs described in BIP. Requires verbal and physical prompting to stay on-task and follow directions 76% or more of the time. Cannot participate in whole class instruction without 1:1 support. Requires prompts to participate in general education and/or interact with peers 76-100% of the time. Step 1 Form 1 3 of 22
Intervention Plan (BIP) Form must be completed when SCI Assessment is requested due to behavioral issues. (Attach a copy of the student s BIP to this form.) Student: SSID#: Date: Age: Grade: Disability: DOB: Gen Ed Teacher: Placement: School: Sp Ed Teacher: Contact Phone: Date of BIP: Case Manager: Contact Phone: What are the target behaviors in the BIP?: Yes No The request for SCIA is related to the identified target behaviors in the BIP. Yes No All interventions are developmentally appropriate for student. Yes No BIP is written with enough clarity and detail for any new staff to understand and implement. Yes No All implementers have a copy of the plan. Yes No The BIP is being fully implemented. Yes No All implementers understand and/or have training in the strategies contained in the plan. Yes No Support for the plan provided by the Case Manager is adequate. Yes No Student is making progress on the target behaviors. Indicate supporting evidence (e.g., grades, rate of homework completion, duration of on-task behavior, frequency, and quality of social interactions). Action(s): BIP is appropriate, and no modifications are needed. Revise BIP. Train support staff. Describe: Comments: Step 1 Form 2 4 of 22
Referral Student: SSID#: Date: Age/Grade: Date of BIP: Disability: DOB: Gen Ed Teacher: Placement: School: SpEd Teacher: Contact Phone: Based on the rubric ratings and other relevant data, please check areas needing further assessment of independence: Least Restrictive Environment Participation in Specialized health plan Participation in G-Tube procedure Medication procedure Suctioning procedure Food preparation Toileting Eating Mobility : Participation in BIP Managing safety (not Physically aggressive) Compliance Staying in designated area : Participation in Discrete Trial/ABA Need for Physical Prompts 80%+ Need for Verbal prompts 80%+ Using Assistive Technology Using Augmentative Alternative Communication (AAC) : Participation in Direct adult instruction Need for Physical support/positioning Need for Safety supervision 80%+ : Previous interventions and results: (Include frequency, duration, and location. Provide summary or attach data sheets from Appendix) How is existing staff in the classroom or site utilized? This referral is made at the request of the: Teacher Parent/Guardian Case Manager Person Completing Referral Date Step 1 Form 3 5 of 22
PARENT Interview Questions (See Appendix for additional Suggested Questions) Student Name: Parent Name: Date: Data Area Informed Suggested Question Notes/Responses Health and Personal Care Based on your experience in the home, which personal care activities would you expect your child to complete independently at school? Which, if any, do you believe he or she may need adult support with at school? Based on your experience at home, how independent is your child in: Staying in a designated area during activities such as meal time, homework time, or TV time? Being mindful of safety during activities such as playing with peers or crossing the street? Completing tasks such as chores or homework? General Questions 1) During which activities is your child most independent and requiring least amount of support? 2) During which activities is your child least independent and requiring most amount of support? 3) What do you see as next steps for your child, such as, area that you would like to see improve? 4) Do you have any safety concerns? 1) 2) 3) 4) Step 3 Form 1 6 of 22
PARENT Interview Questions Step 3 Form 1 7 of 22
Evaluación Para la Independencia de Circunstancias Especiales (SCIA) Cuestionario Para PADRES (See Appendix for additional Suggested Questions) Nombre: Entrevistador: Fecha: Area Preguntas Sugeridas Notas/Respuestas Salud e Higiene Personal Basada en la experiencia del hogar, que actividad referente a la higiene personal usted cree que pueda su hijo(a) llevar a cabo en la escuela independientemente? En que actividad escolar requiere su hijo(a) ayuda de un adulto? Preguntas Generales Preguntas Adicionales Salud/Higiene Personal Comportamiento Instrucción LRE (Ambiente Menos Restringido) Otro Basada en la experiencia del hogar, que tan independiente es su hijo(a) en las siguientes actividades: Permaneciendo en el area asignada durante alguna actividad como el almuerzo, tarea, o viendo la televisión? Siendo consiente sobre la seguridad durante actividades como jugando con sus compañeros o cruzando la calle? Llevando a cabo actividades como tareas o quehaceres del hogar? 1) Durante cuáles actividades es su hijo(a) más independiente requiriendo menos apoyo? 2) Durante cuáles actividades es su hijo(a) menos independiente requiriendo más apoyo? 3) Qué ve como los siguientes pasos a seguir en la educación de su hijo(a), en qué área le gustaría que mejorara su hijo(a)? 4) Tiene alguna preocupación en cuanto a la seguridad de su hijo(a) 1) 2) 3) 4) Step 3 Form 1 (Spanish) 8 of 22
Preguntas Adicionales Salud/Higiene Personal Comportamiento Instrucción LRE (Ambiente Menos Restringido) Otro Preguntas Adicionales Salud/Higiene Personal Comportamiento Instrucción LRE (Ambiente Menos Restringido) Otro Preguntas Adicionales Salud/Higiene Personal Comportamiento Instrucción LRE (Ambiente Menos Restringido) Otro Preguntas Adicionales Salud/Higiene Personal Comportamiento Instrucción LRE (Ambiente Menos Restringido) Otro Preguntas Adicionales Salud/Higiene Personal Comportamiento Instrucción LRE (Ambiente Menos Restringido) Otro Evaluación Para la Independencia de Circunstancias Especiales (SCIA) Cuestionario Para PADRES Step 3 Form 1 (Spanish) 9 of 22
TEACHER Interview Questions (See Appendix for additional Suggested Questions) Student: Teacher: Class/Type: Date: Data Area Informed Suggested Question Notes/Responses Which content area do you feel the student is most independent in? During this content area, approximately how many more prompts does the student need than his/her peers to participate? Which content area do you feel the student is least independent in? During this content area, approximately how many more prompts does the student need than his/her peers to participate? What time of day/content areas have you observed the student need more adult support than his/her peers to demonstrate appropriate behavior? Please be specific. Health and Personal Care What time of day/content areas have you observed the student needing more personal care or medically related activities relative to his/her peers? Step 3 Form 2 10 of 22
TEACHER Interview Questions Least Restrictive Environment If the student participates in general education, about what percentage of the time does the student require adult support to access the curriculum? If the student participates in general education, about what percentage of the time does the student require adult support to interact socially with peers? Step 3 Form 2 11 of 22
TEACHER Interview Questions Step 3 Form 2 12 of 22
STUDENT Interview Questions Student: Person Interviewing: Date: Data Area Informed Suggested Question Notes/Responses Which subjects can you listen and complete work in by yourself? Which subjects do you think you need the most help in from your teacher? Step 3 Form 3 13 of 22
Observation: Environmental Considerations Student: SSID#: Date: Age: Grade: Disability: DOB: Gen Ed Teacher: Placement: School: Sp Ed Teacher: Contact Phone: Start Time: End Time: Observer s Name/Position: SCIA Case Manager: Observation Setting: Please review visual and physical structure of the classroom, curriculum instruction, data collection, and planning. A. Classroom 1. Are individual student/classroom schedules and procedures accessible, if needed? Yes No 2. Are transitions between activities quick and smooth? Yes No Describe: 3. Is room organized with work areas defined and materials readily available for instruction? Yes No Describe: 4. Do students follow established classroom procedures and routines? Yes No Describe: 5. Level of prompt needed for student to follow schedule: Independent Physical prompt Indirect verbal or gesture prompt Direct verbal prompt Describe: 6. Student s use of the schedule: Student checks posted schedule Student carries schedule Student goes to schedule board Schedule not used at all Student uses transition cards Teacher carries and shows the schedule Comments: Step 4 Form 1 14 of 22
B. Curriculum and al Planning 1. Check the curricular domains included in student s program: Academics Functional academics Pre-vocational/vocational Health Self care Communication Motor skills/mobility Social Skills 2. What curricular accommodations and/or modifications are being used? 3. List equipment or devices used that may relate to the need for assistance (e.g., low incidence equipment, assistive technology devices): 4. Are materials and activities age appropriate? Yes No 5. Are materials and activities instructionally appropriate? Yes No 6. Describe lessons observed: Comments: C. Current Data Systems and Collection of Data 1. Has data been collected on student performance? Yes No 2. How often is data collected? Daily Biweekly Weekly Monthly 3. How is data summarized? Graphed Written narrative 4. What evidence is there for accommodations and/or modifications being used? Comments: D. and Safety 1. Describe the behavior management system in the classroom, including positive reinforcers and consequences. Is it appropriate for the student or does it need to be modified? 2. Are specific positive behavior supports utilized for the student? Yes No Describe: 3. Is appropriate safety equipment in place? Yes No 4. Are appropriate safety and medical procedures being used? Yes No Step 4 Form 1 15 of 22
5. Does it appear appropriate training has been provided? Yes No Comments: E. Describe the Student s in Independent Activities 1. Describe the student s interaction with peers. 2. Describe the student s interaction with non-classroom staff in a less structured environment. 3. What activities does the student choose during breaks? 4. What problems are evident? F. Describe the School Day and Assistance Now Provided (Include natural supports such as peers, school staff, volunteers, etc.) G. How is Existing Assistance Utilized? management Curriculum adaptation and preparation Individual Group Medical assistance Supervision H. Can current conditions be modified to meet the student s goals and objectives and/or personal care needs? I. What other types of assistance are needed? Why? J. Are there any other issues that need to be addressed? Comments: Step 4 Form 1 16 of 22
Classroom Observation of Student was referred for a SCIA by the IEP team due to concerns relating to. Observed By: Position: Time/Subject Matter EXAMPLE: 7:30-8:00 Arrive and Breakfast *Observed in a student to teacher ratio of 10:2 for bus and 5:1 for breakfast Observation Notes EXAMPLE: [student name] walks hand in hand with an aide from the bus to the breakfast tables. He walks at a slower pace and required prompting and monitoring to continue along the path. He was given maximum assistance to eat. While the other aide was with a small group, [student name] was in a group of about 5 students. When the aide turned to assist another student in the group, [student name] would attempt to stand and walk away. Requires 2:1 to walk from bus and 1:1 for feeding. Date/Time: Environment: Date/Time: Environment: Date/Time: Environment: Date/Time: Environment: Date/Time: Environment: Step 4 Form 2 17 of 22
Evaluation Report and Independence Plan Student: SSID#: Date: Age: Grade: Disability: DOB: Gen Ed Teacher: Placement: School: Sp Ed Teacher: Contact Phone: SCIA Case Manager: Psychologist: Evaluation Report Prepared By: I. Reason for Referral and Rating from SCIA Rubric II. Background Information and Educational Setting (summarize special education and related services history; educational history, including academic progress/assessments and progress on IEP goals; results of previous evaluations, if applicable; previous interventions and outcomes; educationally relevant health, developmental, and medical findings; review of BIP; and disciplinary referral information) III. Evaluation Procedures (include information regarding administration of tests in primary language of student by qualified personnel; validity of the evaluation; validity of tests for the purpose for which they were used) IV. Summary of Interviews and Observations (summarize results of observations over different settings where the child is displaying the problem behaviors/health concerns/ academic concerns to determine where and when support is needed) V. Summary of Standardized and/or Curriculum-Based Assessments (if applicable) VI. Recommendations (include information regarding the need for specialized services, materials, and equipment; indicate if the student s needs can be met in the regular education classroom with the current level of support) Time/Subject Area Support Needed (Ratio, equipment, materials, etc.) Does support require additional staff? (please check) Step 5 Form 1 18 of 22
Time/Subject Area Support Needed (Ratio, equipment, materials, etc.) Does support require additional staff? (please check) VII. Independence/Fading Plan (The Independence Plan is written to specifically address the needs of the student, current supports, schedule for assistance, and details for implementing and fading the support.) GOALS (What are the replacement behaviors and/or academic goals for the student?) Baselines VIII. Steps to Independence/Fading Plan (Describe the activities or environments where the replacement behaviors should occur). 1) Procedures: [What will be taught so the student learns the replacement behavior/skills? (Task analysis of skill development)] 1a) Arrangements: (Where/When/Materials) 1b) Level of Support: (Description of how and who support changes as student independence increases) Prompting; type; frequency; proximity of personnel; role of teacher/ia 2) Measurement/Progress Monitoring Method: [(Who, How Often, and How will the data be collected) If using a documentation sheet, please attach.] 2a) Decision Rule: (How will the data be evaluated to determine if intervention is working?) 2b) Criteria for fading and a description of the level of SCI support: 3) What are the adaptations/accommodations that will be used to promote and sustain independence?: Respectfully Submitted, Step 5 Form 1 19 of 22
Evaluation Report and Independence Plan Student: SSID#: Date: Age: Grade: Disability: DOB: Gen Ed Teacher: Placement: School: Sp Ed Teacher: Contact Phone: SCIA Case Manager: Psychologist: Evaluation Report Prepared By: I. Reason for Referral and Rating from SCIA Rubric II. Background Information and Educational Setting (summarize special education and related services history; educational history, including academic progress/assessments and progress on IEP goals; results of previous evaluations, if applicable; previous interventions and outcomes; educationally relevant health, developmental, and medical findings; review of BIP; and disciplinary referral information) III. Evaluation Procedures (include information regarding administration of tests in primary language of student by qualified personnel; validity of the evaluation; validity of tests for the purpose for which they were used) IV. Summary of Interviews and Observations (summarize results of observations over different settings where the child is displaying the problem behaviors/health concerns/ academic concerns to determine where and when support is needed) V. Summary of Standardized and/or Curriculum-Based Assessments (if applicable) VI. Recommendations (include information regarding the need for specialized services, materials, and equipment; indicate if the student s needs can be met in the regular education classroom with the current level of support) Time/Subject Area Support Needed (Ratio, equipment, materials, etc.) Does support require additional staff? (please check) Step 5 Form 1 20 of 22
Time/Subject Area Support Needed (Ratio, equipment, materials, etc.) Does support require additional staff? (please check) VII. Independence/Fading Plan (The Independence Plan is written to specifically address the needs of the student, current supports, schedule for assistance, and details for implementing and fading the support.) GOALS (What are the replacement behaviors and/or academic goals for the student?) Baselines VIII. Steps to Independence/Fading Plan (Describe the activities or environments where the replacement behaviors should occur). 1) Procedures: [What will be taught so the student learns the replacement behavior/skills? (Task analysis of skill development)] a) Arrangements: (Where/When/Materials) b) Level of Support: (Description of how and who support changes as student independence increases) Prompting; type; frequency; proximity of personnel; role of teacher/ia 2) Measurement/Progress Monitoring Method: [(Who, How Often, and How will the data be collected) If using a documentation sheet, please attach.] a) Decision Rule: (How will the data be evaluated to determine if intervention is working?) b) Criteria for fading and a description of the level of SCI support: 3) What are the adaptations/accommodations that will be used to promote and sustain independence?: Respectfully Submitted, Step 5 Form 1 21 of 22
Review to Determine Continued Need for Special Circumstance Independence (SCI) Supports Student: SSID#: Date: Age: Grade: Disability: DOB: Gen Ed Teacher: Placement: School: Sp Ed Teacher: Contact Phone: SCIA Case Manager: This form should be completed and this information should be reviewed at the next IEP meeting (within 3-6 months) to determine the effectiveness of SCI support. I. Description of current SCI supports provided (time, settings, specific tasks): II. Observations and update of SCIA Rubric: III. Progress on goal(s) and Independence/Fading Plan (SCIA Evaluation Report and Independence Plan Section V.) update: IV. Recommendations/Comments: Step 7 Form 1 22 of 22