Fidelity of Implementation
Referral for LRE Placement
Student:
Teacher:
Grade:
Age:
School:
Features of Response to Intervention have been implemented with fidelity for the
student.
Yes
No Completion of Functional Behavioral Assessment. All components of the FBA, including
observable behavior, antecedents, consequences, function of problem behavior, and replacement
behavior have been completed.
Yes
No Setting Interventions. Clear and specific setting interventions have been created to reduce
the occurrence of the problem behavior. The student has received evidence-based, individual or
small-group instruction during intervention process.
Yes
No Instructional Interventions. Skills the student needs in order to successfully demonstrate
the replacement behavior have been taught and practiced by the student.
Yes
No Reinforcement and Correction Procedures. Potential reinforcers and correctional
procedures have been developed fully to increase the occurrence of the replacement behavior.
Yes
No Progress Monitoring Data. The student’s progress was monitored with
short-cycle assessment data for at least 3 weeks, using qualified staff member or members.
Yes
No Data-Based Decision Making. The student’s individualized interventions were reviewed,
revised, and/or discontinued based on student performance and progress after 3-week intervals.
Administrator’s Signature: _____________________________________
Date: __________________