Tier 2 Team Meeting
Student Record Sheet
Student Name:
Date Referred:
Counselor:
Revisit Date:
Description of Concern:
Perceived Function of Behavior:
Adult Attention
Peer Attention
Avoid Task/Work
What Other Information Is Needed?
Classroom Observation
Discussion with Parents
Discussion with Teacher(s)
Medical History
Grades
Absent Data
Other:
What Intervention(s) Will Best Meet The Student’s Needs?
Check, Connect and Expect
Social Skills Class
BBBS Mentor
Academic Seminar
Girl’s Circle
Men’s Group
Tutoring
Lunch Bunch
Updates:
Is Student Responding to Tier 2?
Obtain Tangible
Tier 2 Team Meeting
Student Record Sheet – COMPLETED SAMPLE
Student Name: Bart Simpson
Date Referred: 1/21/14
Counselor: Lynass
Revisit Date: 2/5/14
Description of Concern:
Off-task and distracting others during math and science. Currently has a c in math
and a D in science. When directed back on task the students often makes remarks to
the teacher about the assignment such as “ this work is so lame”. He does not show
up for additional support in homeroom time. He is new to this school this year,
moved from Oregon.
Perceived Function of Behavior:
Adult Attention
Peer Attention
Avoid Task/Work
Obtain Tangible
What Other Information Is Needed?
Classroom Observation
Discussion with Parents
Discussion with Teacher(s)
Medical History
Grades
Absent Data
Other:
What Intervention(s) Will Best Meet The Student’s Needs?
Check, Connect and Expect
Social Skills Class
BBBS Mentor
Academic Seminar
Girl’s Circle
Men’s Group
Tutoring
Lunch Bunch
Updates:
Is Student Responding to Tier 2? Check on 2/5/14 and monitor every two weeks.