Fidelity Assurances for SAT Referral
for Evaluation
Tier II
Student:
Teacher:
Grade:
Age:
School:
Features of Response to Intervention have been implemented with fidelity for the
student. Note: all areas need to be in place prior to making a referral for special
education evaluation.
Tier I Fidelity Assurances
Yes
No Evidence-based general education curriculum and methodologies. The
student is placed in a general education classroom where a highly qualified teacher is using
evidence-based curricula and strategies.
If yes, provide rationale and documentation:
If no, describe action step:
Yes
No Fidelity of instruction. The curricula, including extensions, were implemented
with fidelity for this student.
If yes, provide rationale and documentation:
If no, describe action step:
Yes
No Differentiation of Instruction. Specific instructional adjustments and/or
extensions were consistently implemented to meet the student’s needs.
If yes, provide rationale and documentation:
If no, describe action step:
Yes
No (Required fields) Short-Cycle Assessment Data. Short-cycle assessment data of
the student’s performance in academic content areas are collected at least three times a year
and compared to grade level peers in the district. The student scores in the lowest 25% of
his/her peer group based on this data.
If yes, provide rationale and documentation:
If no, describe action step:
Tier II Fidelity Assurances
Yes
No Evidence-based Interventions. The student has received evidence-based
small-group instruction for at least 4 weeks.
If yes, provide rationale and documentation:
If no, describe action step:
Yes
No Fidelity of intervention. The intervention(s) was (were) implemented with
fidelity for this student (including core curriculum, extensions, supplemental curriculum, and
strategies).
If yes, provide rationale and documentation:
If no, describe action step:
Yes
No Progress Monitoring Data. The student’s progress was monitored with
short-cycle assessment data, which was reported to parents. Short-cycle assessment data was
compared to peers and the student’s scores either meet the dual discrepancy or are in the
lowest 10 - 15% of his/her grade level peer group. Weekly curriculum-based measures (CBMs)
were implemented for at least 4 weeks. Data from CBMs are consistent with the area(s) of
concern established by the short-cycle assessment data.
If yes, provide rationale and documentation:
If no, describe action step:
Yes
No Data-Based Decision Making. The student’s individualized or small-group
interventions were reviewed, revised, and/or discontinued based on student performance and
progress after 4 week intervals.
If yes, provide rationale and documentation:
If no, describe action step:
Administrator’s Signature: _____________________________________
Date: __________________
REFERRAL FOR EVALUATION
*If a student has an obvious disability or a serious and urgent problem, the SAT shall address
the student’s needs promptly on an individualized basis, which may include a full and individual
evaluation and determine possible eligibility for special education and related services
consistent with the requirements of 34 CFR Sec. 300.300.
Refer for Section 504 evaluation (Date
/
/
)
For a student suspected of having a physical or mental impairment that substantially
limits a major life activity
Refer for full and individual evaluation (Date
/
/
)
For a student suspected of having a disability and suspected of needing special
education (i.e. specially designed instruction)