THE SCHOOL DISTRICT OF MARTIN COUNTY, FLORIDA

Transcription

1 Rev. 8/26/10 Page 1 of 6 Summary of Concern identified by data team identified by teacher Student: Teacher: School DOB Grade Date: General Description of Concern: Academic or Behavior Differentiated Instruction: current curricula/strategies used to address the concern Formative Assessment(s): used to track the student s academic/behavioral progress and guide instructional decisions Additional Comments:

2 Rev. 8/26/10 Pg 2 of 6 Student: Date: When either a teacher or the data team identifies an academic or behavior concern, a gap comparison should be done to determine at which tier(s) the problem will be addressed. Be sure to look at data that directly assesses the area of concern. Student s present level of performance: Student s expected level of performance: Is there a significant gap between the student and the expectation? Y or N Number of students in the classroom exhibiting this concern: Number of students in the classroom: % of students in the classroom exhibit this concern: Is there a significant gap between the peers and the expectation? Y or N Based on the information above, how will the concern be addressed? (you may check more than one) o Classroom (Core) set up meeting with teacher to discuss and plan o Refer student to Intervention/PS Team Administrator Gen. Ed. Teacher Reading Coach RtI Coach PBS/Beh. Designee Other

3 Page 3 of 6 Individual Intervention Plan Student: Teacher: DOB Grade Date: Step I - Problem Identification: The problem is. Replacement behavior/teachable skill: What do you want the student to do? (specific/observable/measurable) Step II - Problem Analysis: Determine probable causes for the problem by considering relevant information related to instruction, curriculum, environment, and the student. Hypothesis: What are the most likely reasons for this problem? Prediction Statement: How could the instruction, curriculum, and/or environment be changed to enable the student to learn? Hypothesis: The problem is occurring because Prediction Statement: If the problem would be reduced Hypothesis: The problem is occurring because Prediction Statement: If the problem would be reduced.

4 Pg 4 of 6 Student: Step III - Intervention Design: Focus on What to Teach and How to Teach it Describe Intervention: Days of the week (min. 3): Time of Day (min. 30): Who will provide intervention: Where will it be provided: Intervention support will be provided by: Fidelity checks will be done by: Progress Monitoring Plan: Progress monitoring will occur every week(s). Progress monitoring tool(s): What data will be collected: Who is responsible: How will parents be involved? Person(s) responsible for parental involvement: Sharing the data & intervention(s):,, When will Intervention Team reconvene to look at the student s response to intervention: Signatures of Intervention Team Members who developed this Plan / Date: Administrator Gen. Ed. Teacher Reading Coach School Psychologist Guidance Counselor RtI Coach Speech/Lang. Path. Intervention Teacher Parent(s) PBS Rep./Beh. Specialist Other Other

5 Pg 5 of 6 Student: Date: *See attached Graph(s) Step IV Response to Intervention Evaluate the student s progress Positive Response (gap is closing) The team is choosing to: continue intervention with current goal continue intervention with goal increased fade intervention to determine if student has acquired functional independence Next Steps: Questionable Response (gap slows or stops widening, but closure does not occur) Was intervention implemented as intended? No, employ strategies to increase implementation integrity Yes, increase intensity of current intervention for a short period of time and assess impact. If rate improves, continue. If rate does not improve, return to problem solving Step 1 on page 3 Next Steps: Poor Response (gap continues to widen with no change in rate) Was intervention implemented as intended? No, employ strategies to increase implementation integrity Yes Is intervention aligned with verified hypothesis? (page 3) Are there other hypotheses to consider? (page 3) Was the problem identified correctly? (page 3) Next Steps:

6 Pg 6 of 6 Student: Signatures of Intervention Team Members who evaluated the student s Response to Intervention and made Recommendations for Next Steps / Date: Administrator Gen. Ed. Teacher(s) Reading Coach School Psychologist Guidance Counselor RtI Coach Speech/Lang. Path. Mainstream Consultant Intervention Teacher Parent(s) PBS Contact/Beh. Specialist Other If parents were not at this meeting, please indicate who, when and how the parent will be involved: Attach form #114 to document conversation Who: When: How: