Secondary Multi-Tiered System of Support Project Application
SECTION I: DISTRICT INFORMATION
LEA INFORMATION
Contact Information
3 digit School Code (LEA#)
Name of LEA
LEA Contact/
Coordinator
Highlight the
percentage of schools in
your LEA implementing
a three tier model of
MTSS or RtI
Highlight the
percentage of schools in
your LEA who are using
a student’s
responsiveness to
scientific research
based interventions as
part of a
comprehensive
evaluation for
determining SLD
eligibility.
Name
Phone
Email
Address
0
1-25%
51-75%
76-99%
100%
0
1-25%
51-75%
76-99%
100%
GRANT REQUIREMENTS
Please indicate “yes” if you agree to the following requirements:
RtI/MTSS is currently implemented in all elementary schools that feed
into the applying middle school. The selected high school must be in the
same feeder pattern as the elementary school(s) and selected middle
school.
Adoption and full-scale implementation of MTSS in one middle and one
high school in a feeder pattern over a three year period.
Active participation by school administration in MTSS Leadership Team
meetings, professional development, data-driven decision making and
other elements crucial to successful implementation of MTSS.
Establishment of an MTSS leadership team at each site. The team will
include building administration and teacher leaders, including school
improvement team members. The team will meet and communicate
DRAFT L. Loeser
4/30/14
District
Middle
School
High
School
Secondary Multi-Tiered System of Support Project Application
regularly with NCDPI staff, NCDPI MTSS regional consultants and
external professional developers and coaches provided through the
grant.
Commitment of technical support from District level staff (i.e. MTSS/
PBIS coordinators, instructional coaches) to the LEA sites in the
secondary MTSS grant project. District will facilitate the removal of
barriers to implementation.
Support the professional development and ongoing coaching necessary
for the implementation of core elements of MTSS, including literacy,
math and behavior supports.
Conduct a review of MTSS implementation progress twice yearly with
follow up action planning.
Commit to sending required team members to grant-sponsored
professional development opportunities.
Establish an implementation plan by district leadership to scale up MTSS
to other secondary sites within the district.
Commit to the use of a comprehensive, balanced assessment system
(including universal screening and progress monitoring) to evaluate the
health of Core instruction, identify students at risk and to monitor
progress.
Commit to using a student’s responsiveness to scientific research-based
interventions as part of a comprehensive evaluation for eligibility
decisions for students with a disability.
Serve as a model demonstration site for other NC LEAs.
If yes is checked to all of the above, please proceed to the remaining sections.
DRAFT L. Loeser
4/30/14
Secondary Multi-Tiered System of Support Project Application
DISTRICT IMPROVEMENT GOALS AND INITIATIVES
1. List the goals on your district improvement
plan specific to academic achievement in
literacy, math and behavior.
2. Under which goal(s) does MTSS fit? What
strategies are stated in the district
improvement plan to achieve this goal?
3. What other district initiatives are currently being implemented? Complete the attached District
Initiative Inventory.
4. What other district initiatives will soon start? Please state the rationale for selecting the initiative
and the evidence-based decision-making involved to adopt this initiative.
5. Describe the district coaching plan to assure sustainability of district initiatives.
6. Describe the structures that are in place to assure high quality instruction is provided to all students.
DRAFT L. Loeser
4/30/14
Secondary Multi-Tiered System of Support Project Application
7. Describe the structures that are established to analyze data for data-driven decision making.
8. Identify and describe the sources of data that are used to drive decisions. Include formative and
summative assessment data.
DISTRICT RtI/MTSS IMPLEMENTATION
9. Have district staff attended NCDPI RtI training in the past three years? If so, identify the date,
location, staff members and role of those who attended.
10. Describe your current district implementation of RtI or MTSS. Include a description of the
professional development, activities and structures that have been installed.
11. Does the district currently have existing staff who dedicate a portion of their time to RtI/MTSS? If
so, please provide their name, role and responsibilities for RtI/MTSS.
DRAFT L. Loeser
4/30/14
Secondary Multi-Tiered System of Support Project Application
PROJECT GOALS
12. If selected for this project, what are you hoping to accomplish through this grant?
SECTION II: MIDDLE SCHOOL INFORMATION
MIDDLE SCHOOL PROFILE
Contact Information
6 digit School Code (LEA# + School#)
Name of School
Address
Telephone Number
Fax
Name
Principal
Phone
Email
DRAFT L. Loeser
4/30/14
Secondary Multi-Tiered System of Support Project Application
Grade Levels Served
Elementary Feeder School(s)
High School Feeder School(s)
MIDDLE SCHOOL IMPROVEMENT GOALS AND INITIATIVES
13. List the goals on your school improvement
plan specific to academic achievement in
literacy/math and behavior.
14. Under which goal(s) does MTSS fit? What
strategies are stated in the school
improvement plan to achieve this goal?
15. What other school improvement initiatives are currently being implemented? Complete the
attached School Initiative Inventory.
16. What other school improvement initiatives will soon start? Please state the rationale for selecting
the initiative and the evidence-based decision-making involved to adopt this initiative.
17. Describe the professional development activities staff have participated in this school year. Add
additional rows as needed.
TOPIC
AUDIENCE
LENGTH (i.e. 1 hr. full day,
monthly)
18. Describe the coaching plan and follow up to professional development to assure sustainability of the
initiative.
DRAFT L. Loeser
4/30/14
Secondary Multi-Tiered System of Support Project Application
19. Describe the structures that are in place to assure high quality instruction is provided to all students.
20. Describe the structures that are established to analyze data for data-driven decision making.
21. Identify and describe the sources of data that are used to drive decisions. Include formative and
summative assessment data.
MIDDLE SCHOOL MTSS IMPLEMENTATION
22. Have school staff attended NCDPI RtI training in the past three years? If so, identify the date,
location and staff members and role of those who attended.
23. Describe your current implementation of RtI or MTSS. Include a description of the professional
development, activities and structures that have been installed.
24. Are you a PBIS school? If so, indicate number of modules trained (1-3).
PROJECT GOALS
25. If selected for this project, what are you hoping to accomplish through this grant?
DRAFT L. Loeser
4/30/14
Secondary Multi-Tiered System of Support Project Application
SECTION III: HIGH SCHOOL INFORMATION
HIGH SCHOOL PROFILE
Contact Information
6 digit School Code (LEA# + School#)
Name of School
Address
Telephone Number
Fax
Name
Principal
Phone
Email
Grade Levels Served
Elementary Feeder School(s)
Middle Feeder School(s)
HIGH SCHOOL SCHOOL IMPROVEMENT GOALS AND INITIATIVES
26. List the goals on your school improvement
plan specific to academic achievement in
literacy/math and behavior.
27. Under which goal(s) does MTSS fit? What
strategies are stated in the school
improvement plan to achieve this goal?
28. What other school improvement initiatives are currently being implemented? Complete the
attached School Initiative Inventory.
29. What other school improvement initiatives will soon start? Please state the rationale for selecting
the initiative and the evidence-based decision-making involved to adopt this initiative.
DRAFT L. Loeser
4/30/14
Secondary Multi-Tiered System of Support Project Application
30. Describe the professional development activities staff have participated in this school year.
TOPIC
AUDIENCE
LENGTH (i.e. 1 hr. full day,
monthly)
31. Describe the coaching plan and follow up to professional development to assure sustainability of the
initiative.
32. Describe the structures that are in place to assure high quality instruction is provided to all students
(i.e. fidelity checks, classroom walk-throughs).
33. Describe the structures that are established to analyze data for data-driven decision making.
34. Identify and describe the sources of data that are used to drive decisions. Include formative and
summative assessment data.
HIGH SCHOOL MTSS IMPLEMENTATION
35. Have school staff attended NCDPI RtI training in the past three years? If so, identify the date,
location and staff members and role of those who attended.
36. Describe your current implementation of RtI or MTSS. Include a description of the professional
development, activities and structures that have been installed.
37. Are you a PBIS school? If so, indicate number of modules trained (1-3).
DRAFT L. Loeser
4/30/14
Secondary Multi-Tiered System of Support Project Application
PROJECT GOALS
38. If selected for this project, what are you hoping to accomplish through this grant?
SECTION IV: Signatures
Signatures below affirm commitment to implementing MTSS and agreement to fully participate
in ongoing assessment of implementation.
Signature
Superintendent
Middle School Principal
High School Principal
Secondary Director(s) or
equivalent
Exceptional Children Director
RtI/MTSS/PBIS Coordinator(s), if
applicable
DRAFT L. Loeser
4/30/14
Date
Secondary Multi-Tiered System of Support Project Application
DRAFT L. Loeser
4/30/14