SBLC Referral Team Forms
SBLC Referral Team Forms
Table of Contents
Consent Form to Allow Accompanying Person at Meetings ............................................. 1
SBLC Referral Team Meeting Notification-SBLC 1 ........................................................ 2
SBLC Referral Team Documentation-SBLC 2 ................................................................. 3
SBLC Referral Team Documentation-SBLC 3 ................................................................. 4
Gifted Screening Form ..................................................................................................... 5
Teacher Interview for Possible Gifted .............................................................................. 6
Visual Arts Screening Form ............................................................................................. 7
Theatre Screening Form ................................................................................................... 8
Music Screening Form ..................................................................................................... 9
Communication Skills Teacher Checklist ....................................................................... 10
Medical Release of Information ..................................................................................... 11
Hearing/Vision Screening............................................................................................... 12
Sensory Processing Screening ........................................................................................ 13
Sensory Processing Intervention Strategies .................................................................... 15
Motor Screening Form ................................................................................................... 19
Health Services Screening .............................................................................................. 22
Assistive Technology Screening ..................................................................................... 21
Behavior Documentation Forms ..................................................................................... 26
CADDO PARISH PUBLIC SCHOOLS
Revised 7-1-15
DEPARTMENT OF EXCEPTIONAL CHILDREN
2226 Murphy Street
Shreveport, Louisiana 71103
Telephone: (318) 603-6700 ~ FAX: (318)
CONSENT TO ALLOW ACCOMPANYING PERSON TO
DISCUSS/REVIEW RECORD(S) AT MEETING(S)
FOR USE BY PARENT OR ELIGIBLE STUDENT TO GRANT CONSENT
Student Name:
Date of Birth:
Address:
City/State:
School:
Zip Code:
Student Number:
I hereby grant permission for
to accompany
Name of Person
me today during my scheduled meeting. I understand that in doing so, information will be discussed and reviewed that is protected by
the Family Educational Rights and Privacy Act (FERPA) and state laws and may be disclosed with my consent to the above individual.
Signature:
Print Name:
Date:
FOR USE BY ACCOMPANYING PERSON AS AFFIDAVIT ON NONDISCLOSURE
In accompanying the above-signed parent/guardian on this date I will be given access to confidential information maintained in the
records of the named student. I understand that this information is protected under FERPA. I hereby acknowledge that I fully
understand that the intentional release by me of this information to any unauthorized person could subject me to penalties imposed
by FERPA and state laws. I understand that identification in the form of a driver’s license or other form of photo ID must be presented.
Signature:
Print Name:
Date:
   Identification will be required in the form of a driver’s license or other form of photo I.D.
   Unless otherwise revoked, this authorization will expire 60 days from the original date.
Instructional Specialist/Lead Teacher/School Administrator Signature
Original – DEPARTMENT OF EXCEPTIONAL CHILDREN
Copy to SCHOOL
1
Date
Copy to PARENT/GUARDIAN
SBLC 1 / 7-1-15
2
SBLC REFERRAL MEETING NOTIFICATION
Student: __________________________________________________________________________
School:_______________________________ School Telephone #: __________________________
1st ___ 2nd ___ 3rd ___ 4th Meeting
SBLC Notification: ____________________________
(date SBLC 1 sent)
Dear Parent / Legal Guardian:
The School Building Level Committee (SBLC) at your child’s school will meet to discuss his or her
progress. During the meeting, information about your child will be reviewed and appropriate educational
decisions will be made. Please plan to attend the meeting as your input is valuable. We look forward to
meeting with you!
SBLC Date: ____________________
Time: ________________
One or more educational screenings may be conducted by school personnel and important educational
information about your child’s school performance will be gathered prior to this meeting.
The purpose of this meeting is to discuss your child's:
Academic Performance
Pupil Progression
Behavior
Medical Needs
Communication Needs
Motor Difficulties
Possible Gifted/Talented Skills
Parent Request
Section 504 Evaluation/IAP Annual Update
Check one of the following:
_____ YES, I can attend the meeting
*_____ NO, I cannot attend the meeting
*A better date/time would be: _________________________________
Sign and return as soon as possible!
Home / Work Telephone #’s
Parent / Guardian Signature
If you have any questions, please contact me at the school number noted above.
Sincerely, _________________________________________________________
SBLC Chairperson / Principal / Principal Designee
School Use Only:
DOCUMENTATION
Date(s) of telephone call(s):
Date(s) reminder notice(s) sent:
Notes: __________________________________________________________________________________
WHITE – Section 504/Pupil Appraisal
YELLOW - School
2
PINK - Parent
SBLC 2/Revised 7-14
SBLC REFERRAL TEAM DOCUMENTATION
A review of all current behavior data including universal screenings as well as major and
minor discipline reports indicates:
Student displays appropriate behavior when compared to peers of the same grade (attach school/class data
including results of the universal screening). The PBIS and classroom plans are sufficient.
Behavior difficulties exist, but may be modified using Tier 1 - universal design strategies or Tier 2 Supports
Problem Behavior(s): _______________________________________________________________
When do the Behaviors Occur? ________________________________________________________
Consequence(s): ___________________________________________________________________
Purpose of Behavior(s):
Avoid/Escape __________________
Obtains ________________
Current Level of Functioning: _________________________________________________________
(How often does it occur? How long does it last? How severe?)
Goal/Date (May be Revised): _________________________________________________________
Further data collection is warranted. A detailed Functional Behavior Assessment will be completed.
The student’s behavior appears to be an immediate danger to himself or others. Consult with Pupil Appraisal staff.
Rule Out Factors
The following factors can be ruled out as the primary cause of the lack of educational progress:
Lack of appropriate, explicit, and systematic instruction in reading which included the essential
components of reading instruction: phonics, phonemic awareness, fluency, comprehension, and
vocabulary;
Lack of appropriate instruction in math;
Limited English proficiency;
ELL Evaluation Results: ___________________________________________________________
Language Spoken at Home: _____________________
Environmental or economic disadvantage;
Cultural factors
3
At School: _______________________
SBLC 3/Revised 7-1-15
SBLC REFERRAL TEAM DETERMINATION
Student:
School:
School Telephone #: _______________________
SBLC Date:
SBLC Notification: _______________________________________
(date SBLC 1 sent)
SBLC Referral Concern(s): ____________________________________________________________________________
Dear Parent / Legal Guardian:
Below is the result of this Referral Team meeting. Please contact the Referral Team Chairperson if you have questions or disagree with this
decision. If you disagree, we are required to provide you with the “Caddo Parish Public Schools Guide to: Section 504 of the Rehabilitation
Act of 1973”and/or the “Louisiana's Educational Rights of Children with Disabilities”
COMMITTEE DECISION:
Conduct no further action at this time
Continue current intervention and progress monitoring through RTI process
Conduct additional interventions through the RTI process
Refer the student to the appropriate committee to conduct a section 504 Evaluation
Refer to Pupil Appraisal for support services (Pupil Appraisal Representative must be present)
Refer to Pupil Appraisal for an individual evaluation (Pupil Appraisal Representative must be present)
Consideration of grade retention/ Promotion with remediation
Other: ___________________________________________________________________________________
Additional SBLC comments: ___________________________________________________________________
SCHOOL BUILDING LEVEL SCREENING COMMITTEE MEMBERS
*Required members
SBLC Chairperson* ________________________________ (Principal / Principal Designee)
Pupil Appraisal __________________________Referring Teacher*
__
Classroom Teacher*______________________ Section 504 Designee ___________________
Other ___________________________________Other ________________________________
Parent / Legal Guardian:
(Check One)
I agree with the committee decision noted above.
I disagree with the committee decision noted above. I have received a copy of the
“Caddo Parish Public School’s Guide to: Section 504 of the Rehabilitation Act of 1973”
and/or the “Louisiana’s Educational Rights of Children with Disabilities
Parent / Legal Guardian Signature*
Check if Appropriate:
Parent / Legal Guardian invited but did not attend.
Section 504/Pupil Appraisal
School
4
: Parent
PAR 22S
Revised 7-1-15
GIFTED SCREENING FORM
Student Name:_____________________________________________________
School:_____________________________
Grade:__________
Date: _________________
Race:___________
Age:__________
Person completing this form (PLEASE PRINT): _____________________________________________________
Is this student receiving speech therapy?
____YES
____NO
Are communication skills a concern?
____YES [Refer student to the referral team]
Are there any other concerns?
____YES
____NO
___NO
If YES, please explain:_______________________________________________________________________
Most recent parent/teacher conference date: ________________________ (Required)
Does a review of the student’s educational history and *universal screening results support this recommendation
for evaluation? ____YES ____NO
If NO, explain:_____________________________________________________________________________
*ATTACH COPY OF UNIVERSAL SCREENING RESULTS
(REQUIRED)
HEARING
VISION
____No hearing problem currently suspected
____No vision problem currently suspected
Complete most currentV/H-I, if problems are suspected.
Circle the student's aptitude range and achievement test scores on the matrix. Enter the academic test scores,
matrix points and name of administered tests in each of the three areas in the spaces provided. If the student
earns the required matrix points utilizing achievement data only, additional testing in aptitude is not required.

Gifted screening uses a combination of test results to determine matrix points. The following tests can
be given to obtain percentile scores in reading and math: statewide assessment or WRAT 4, or STAR
ENTERPRISE, or TERRA NOVA.
 K-BIT 2 is recommended for the aptitude score.
 Preschooler’s require only an aptitude score, which must be in the 90th percentile or greater to be
referred for evaluation.
 Kindergarten students must obtain at least 8 points on the screening matrix, one of which must be in
aptitude, and a strong recommendation (check characteristics list) from the teacher. All other students
may be referred with a total of 4 points, in any combination, and a strong recommendation from the
teacher.
 If the student passes screening, this form, the K-BIT 2 protocol, WRAT 4 protocol or statewide
assessment, or STAR ENTERPRISE, or TERRA NOVA scores and universal screening results must be
attached.
 If the student does not pass screening, this form will remain in the student's cumulative record. K-Bit 2
and WRAT 4 protocols are to be sent to the Gifted Department at the Department of Exceptional
Children to ensure test security.
(OVER)
5
PAR 22T
Revised 7-1-15
CADDO PARISH PUPIL APPRAISAL
DEPARTMENT OF EXCEPTIONAL CHILDREN
TEACHER INTERVIEW FORM FOR POSSIBLE GIFTED
STUDENT___________________________________
TEACHER _______________________________
SCHOOL____________________________________
GRADE________
DATE________________
PERSON COMPLETING THIS FORM: ____________________________/________________________
Print
Signature
This form is designed to obtain your estimate of a student's potential. We depend on your expertise to help
us identify students who may qualify for further testing.
Please indicate the five main attributes that best describe this student:
___Superior academics
___Creative/Imaginative
___Leader
___Inquisitive
___Critical thinker
___Self-motivated
___Problem solver
___Works to potential
___Wide range of interests
___Good peer relations
___Sense of humor
___Sensitive to needs of others
___Task committed
___Exceptional ability to
___Highly expressive
___Insightful
___Excels in reading
retain & retrieve information
___Good reasoning ability
___Excels in math
___Other___________________________________________________________________________
6
Caddo Parish Public Schools
Talented Arts: Visual Arts Screening Instrument
Student:
School:
Date Screener Provided: ____/____/____
Date to Return: ____/____/____
Directions: Your ratings should be based on the student’s actual observable behavior. Please rate the
student on each of the following items by circling the appropriate number in the column on the right. Each
item receiving a score of four or 5 on the rating scale must be documented with 3 examples, or samples
of the student’s work, whichever is more appropriate. Notations of these must be made in the
justification area.
Seldom
Never
1
Occasionally
Average
Usually
2
3
4
Almost
Always
5
Draws better than his/her peers
Justification:
1
2
3
4
5
Volunteers to do art or art-like activities
Justification:
1
2
3
4
5
Deferred to by other students when drawing
or making projects
Justification:
1
2
3
4
5
Brings drawing or art made at home to school
Justification:
1
2
3
4
5
Sets high standards of quality for his/her
artwork
Justification:
1
2
3
4
5
Reacts with interest to art activities and
information.
Justification:
1
2
3
4
5
Student Behavior
Draws more than his/her peers
Justification:
Referring Teacher Signature:
VISUAL ARTS Screening Total:
/ 35 points
7
+ 33 = pass
< 32 = did not pass
Caddo Parish Public Schools
Talented Arts: Theatre Screening Instrument
Student:
School:
Date Screener Provided: ____/____/____
Date to Return: ____/____/____
Directions: Your ratings should be based on the student’s actual observable behavior. Please rate the student on
each of the following items by circling the appropriate number in the column on the right. Each item receiving a score
of four or 5 on the rating scale must be documented with 3 examples, or samples of the student’s work, whichever is
more appropriate. Notations of these must be made in the justification area.
Seldom
Never
1
Occasionally
Average
Usually
2
3
4
Almost
Always
5
Shows leadership in group activities, but follows
when appropriate
Justification:
1
2
3
4
5
Shows emotion and feels with others in shared
school experiences
Justification:
1
2
3
4
5
Shows freedom in using facial expression,
gestures, and body
Justification:
1
2
3
4
5
Shows ability to focus on the activities at hand
Justification:
1
2
3
4
5
Stays with a task until it is successfully completed
Justification:
1
2
3
4
5
Shows imagination in deciding how to proceed
with a problem
Justification:
1
2
3
4
5
Responds to activities in elaborate details
Justification:
1
2
3
4
5
Shows ability to mimic physical and vocal behavior
of others
Justification:
1
2
3
4
5
Volunteers to perform in front of people
Justification:
1
2
3
4
5
Student Behavior
Effective in vocally communicating
ideas/directions/feelings to others
Justification:
Referring Teacher Signature:
THEATRE Screening Total:
____ / 50 points
+ 47 = pass
Caddo Parish School Board
< 46 = did not pass
Revised 7-1-15
8
Caddo Parish Public Schools
Talented Arts: Music Screening Instrument
School:
Student:
Directions: Your ratings should be based on the student’s actual observable behavior. Please rate the
student on each of the following items by circling the appropriate number in the column on the right. Each
item receiving a score of four or 5 on the rating scale must be documented with 3 examples, or samples
of the student’s work, whichever is more appropriate. Notations of these must be made in the
justification area.
Seldom
Never
1
Occasionally
Average
Usually
2
3
4
Almost
Always
5
Is eager to participate in musical activities
Justification:
1
2
3
4
5
Is sensitive to the rhythm of the music;
responds through body movements to
changes in tempo of the music
Justification:
1
2
3
4
5
Shows exceptional and/or fluent use of
original, creative or divergent ideas
Justification:
1
2
3
4
5
Plays one or more musical instruments (or
expresses a desire to); and/or sings with
confidence
Justification:
1
2
3
4
5
Demonstrates a high level of concentration
for a sustained period of time
Justification:
1
2
3
4
5
Is recognized by peers as talented in music
Justification:
1
2
3
4
5
Student Behavior
Shows interest in and enjoyment of musical
activities
Justification:
Referring Teacher Signature:
MUSIC Screening Total:
__________________
/ 35 points
+ 33 = pass
9
< 32 = did not pass
Caddo Parish School Board
Communication Skills Teacher Checklist
Revised 7-1-15
Student________________________________________
DOB__________________________
Grade ___________
Teacher________________________________________
School________________________________________
Date of Parent Contact by Teacher (Regarding Communication Concerns): _____________________________________
Please check TRUE or FALSE for each of the following statements.
ARTICULATION (Speech Production)
_____ TRUE
_____ FALSE
The student’s articulation skills appear normal with respect to age and social/cultural factors.
_____ TRUE
_____ FALSE
The student uses clear, correct and understandable speech sounds.
_____ FALSE
The student exhibits normal voice quality.
VOICE
_____ TRUE
SPEECH FLUENCY
_____ TRUE
_____ FALSE
The student speaks fluently without sound or word repetitions, revisions, or fillers (stuttering)
LANGUAGE
(Expressive & Receptive)
_____ TRUE
_____ FALSE
The student follows oral directions accurately and without the need for multiple repetitions.
_____ TRUE
_____ FALSE
The student listens to stories presented orally and re-tells them accurately.
_____ TRUE
_____ FALSE
The student answers and asks questions in an age appropriate manner. (WH, Y/N)
_____ TRUE
_____ FALSE
The student orally formulates sentences correctly.
(Pragmatic Language)
_____ TRUE
_____ FALSE
_____ TRUE
_____ FALSE
_____ TRUE
_____ FALSE
The student uses language that is relevant and appropriate to the situation.
The student interacts in a socially appropriate manner (initiates interactions, takes turn in
conversations, observes personal space, etc.)
The student maintains topic and conversation in an age appropriate manner.
Please check one.
This student’s communication skills (articulation, voice, fluency, and language) appear to be adequate, and this student
does not have a communication problem that adversely affects educational progress with regard to grades, behavior,
class participation, or oral speaking abilities.
In my opinion, this student has a communication problem that adversely affects educational progress in a significant
way.
_____________________________________________________
Teacher
_______________________________________
Date
Date of teacher follow up by SLP: _________________________(Attach RtI Classroom Observation)
We agree that a speech-language screening
is
____________________________________________
is NOT warranted at this time. (sign below)
___________________________________________
Teacher
SLP
10
11
Revised 7-1-15
V/H-I
HEARING / VISION SCREENING RESULTS
(required for enrolled and non-enrolled students)
Student: _____________________________________ DOB: _____________
School:_______________________________
Teacher: ____________________________________ (attach student class schedule)
Grade: ______________________
Requested by: ______________________________________ (name/title) Screening Request Date: ___________________
Vision/Hearing Screening Completed by (signature): ______________________________ Date Screened: ______________
Required on all initial and re-evaluations, when a disability is suspected.
HEARING
Screened At: ____ 20dB
____ 25dB
Right Ear: ____ 4000 Hz ____ 2000 Hz ____ 1000 Hz (____ Pass ____ *At-Risk)
Left Ear:
____ 4000 Hz ____ 2000 Hz ____ 1000 Hz (____ Pass ____ *At-Risk)
*AT-RISK: failure to respond (one ear) at 20db at one frequency; or at 25db at two or more frequencies
VISION
For students with prescribed glasses:
____ Screened with glasses____ Screened without glasses
Vision screening must include tests for three conditions: Acuity, Color Perception and Muscle Balance
(Acuity: Far point for 3yrs. old through 1st grade / Near and far point for grades 2 through 12 students)
FAR POINT ACUITY:
Right Eye: 20/____
Left Eye: 20/____
(____ Pass ____ *At-Risk)
(____ Pass ____ *At-Risk)
NEAR POINT ACUITY:
Right Eye: 20/____
Left Eye: 20/____
(____ Pass ____ *At-Risk)
(____ Pass ____ *At-Risk)
MUSCLE BALANCE:
Near Eye (____ Pass ____ *At-Risk)
Far Eye (____ Pass ____ *At-Risk)
COLOR BLINDNESS:
____ Pass ____ *At-Risk (____ Student under the age of 8)
____ Vision and Hearing Screening Results were copied from ELECTRONIC RECORDS
*AT-RISK: failure in any one area in either eye or both eyes
____ Unable to respond appropriately to the formal screening due to age and degree of involvement. Therefore, informal
hearing test results indicated
at risk results.
adequate results for educational purposes.
____ Adapted vision screening methods indicated
at risk results.
adequate results for educational purposes.
*Requires comments: [Was the parent/legal guardian notified in writing? (attach copy) Was a referral made? Who will provide
follow-up?] ____________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________
12
Revised 7-1-15
SENSORY PROCESSING SCREENING
Instructions for Use
1.
2.
3.
4.
5.
6.
7.
8.
9.
Prior to the first RTI meeting, the Sensory Processing Screening
Checklist (SPS1) is completed by the student’s general education
teacher(s).
The RTI chairperson reviews the completed screening checklists to
determine if there are difficulties that require intervention according to
the Sensory Processing Screening Criteria (SPS2).
When interventions are necessary, the RTI Committee targets the sensory
area of greatest concern.
Sensory Processing Intervention Strategies (SPS3) are then selected to
address the targeted area of concern.
Intervention strategies are implemented by the student’s teacher(s) for the
length of time designated by the RTI Committee.
Following the intervention period, the teacher records the intervention results
on the SPS3.
Intervention results are reviewed by the RTI Committee.
For students who are “at risk” for sensory processing deficits, but are not
suspected of having a disability, the RTI Committee targets additional
interventions to be implemented by the classroom teacher(s).
For students who are suspected of having a disability, the RTI Committee
obtains a second Sensory Processing Screening Checklist
(following intervention) to determine if further assessment is warranted
according to Sensory Processing Screening Criteria (SPS2).
13
Revised 7-1-15
Student:___________________________Teacher:___________________________Date:_________
Sensory Processing Screening Checklist SPS1
Check the column that best describes how frequently the student exhibits each behavior.
Almost
Never
<25%
SENSORY AREAS
VISUAL
Visual details/stimuli interfere with task completion
Unable to locate and/or organize materials and supplies
Reacts to small changes in classroom
Comments:
AUDITORY
Overreacts to loud or unexpected noises (e.g., intercom, fire drill)
Exhibits distress during lunch, P.E., assemblies
Background noises hinder task completion
Talks incessantly
Requires repeated oral directions in class more than others
Comments:
TACTILE
Overreacts to unexpected or light touch
Withdraws/isolates self from others
Touches people or their things to the point of irritation
Fidgets with objects
Has difficulty standing in line or close to other people
Uses only fingertips to manipulate classroom materials
Refuses to participate in messy activities
Comments:
VESTIBULAR/PROPRIOCEPTIVE
Exhibits movement which interferes with classroom
functioning/unable to stay in designated area/walks around
Fidgets during activities (e.g., wiggles in seat, taps on desk)
Leans out of desk or seat/rests head on desktop
Becomes overly excited after movement activity
Bumps/pushes/hits/runs into things or others
Withdraws from active environments or situations
Avoids climbing or playground equipment
Comments:
OLFACTORY AND GUSTATORY
Chews/eats non-edible items (e.g., clothing, pens, pencils)
Comments:
BEHAVIORAL RESPONSE
Has tantrums for no apparent reason
Has difficulties with changes in routines
Is rigid or set in his/her ways
Overreacts or is dramatic compared to peers
Appears lethargic
Comments:
14
Occasionally
<50%
Frequently
<75%
Almost
Always >75%
Revised 7-1-15
SENSORY PROCESSING SCREENING CRITERIA (SPS2)
Based upon the results of the Sensory Processing Screening Checklist (SPS1), the
following screening criteria are used to determine when:
a. Interventions are necessary
b. Further assessment is needed should the student be referred for evaluation
CRITERIA
The student exhibits:

8 or more behaviors in the “Almost Always” category
OR

11 or more behaviors in the “Frequently” and “Almost Always” categories
combined.
Suggested interventions for each sensory area (i.e., visual, auditory, tactile, etc.) are
included in the Sensory Processing Intervention Strategies (SPS3). The intervention(s)
should initially target the sensory area of greatest concern and may require more than one
strategy.
15
Revised 7-1-15
Page 1
Sensory Processing Intervention Strategies (SPS3)
Student:_________________________
Teacher:_______________________
Date Intervention
Starts
Visual
Limit/eliminate visual clutter within classroom such as busy bulletin boards, artwork items, hanging from ceiling, etc.
Organize classroom materials in bins or behind curtained shelves
Provide preferential seating for better view of blackboard as well as to reduce visual distractions
Color code and clearly label materials and supplies
Modify classroom lighting by dimming lights, closing or opening shades/blinds, etc.
Provide consistent independent work area with visual boundaries as needed (e.g., use partition, carrel, or tape to
provide boundaries)
Intervention results:
Auditory
Provide white noise or classical music as appropriate to mask background noises
Cover intercom to mute volume level
Use headphones or earplugs to muffle sounds
Provide verbal or visual warning when possible for fire drills, bells, and morning announcements
Give visual directions rather than verbal
Teach positive self-talk (e.g., “It’s only a fire drill. It won’t hurt me.”)
Encourage child to put hands over ears and let him/her know “it’s ok”
Place tennis balls on legs of chairs, rugs on classroom floor, or carpet squares under desk to reduce noise
Provide seating around perimeter of noisy cafeteria or auditorium
Provide either verbal or physical cue such as touching lips or tapping on shoulder to remind student it is not an
appropriate time to talk
Provide “Talk card” so only student with card is allowed to talk
Give oral directions when in close proximity to student, breaking directions down into small steps
Have student repeat directions back to teacher
Intervention results:
16
Date Intervention
Ends
Revised 7-1-15
Page 2
Date Intervention
Starts
Date Intervention
Ends
Tactile
Limit amount of touching/warn student ahead of time of possible touch
Have child who touches too much carry weighted object (e.g., binder, book)
When walking in line, have all students fold arms or put finger on lips
Place student either in front of line or back of line to decrease proximity to others
Use preferential seating to avoid touch (e.g., place desk at outside edge of classroom desks)
Use carpet square or boundary to indicate where the child needs to remain
When possible, have students sit at every other seat in cafeteria
Have wet wipes readily available for immediate clean-up following a messy activity, thereby reducing possible student
anxiety about participating
Allow student to perform non-preferred tactile activities with a tool (e.g., use a brush, popsicle stick, Q-tip, etc.) or
while wearing gloves
Use novel or fun manipulatives to desensitize such as dried beans, Mardi Gras beads, Easter grass, water table,
packing peanuts, etc.
Intervention results:
Vestibular/Proprioceptive
DO NOT penalize student by removing recess time as student needs appropriate time for movement such as
running, jumping, swinging, etc.
Provide naturally occurring movement opportunities such as delivering messages, cleaning boards, obtaining and
returning heavy materials to/from shelving (e.g., books)
Have student wear backpack containing his/her books during transitions and movement breaks
Provide clear boundaries for seating such as taped area, carpet square, etc.
Allow time for student to “chill out” following movement activity (e.g., take three deep breaths before transitioning,
allow stretching between activities, allow water breaks)
Provide appropriate objects for fidgeting
Have student give self bear hugs, or perform chair pushups
Assist with decorating bulletin board by stapling decorations or stapling papers for teacher
Allow use of Ellison cutout machine for bulletin board decorations
Allow student to help rearrange desks or pick up chairs at end of school day
Revised 7-1-15
17
Page 3
Date Intervention
Starts
Olfactory and Gustatory
Consider letting student chew on candy, gum, tooth brush, straw, or coffee stirrer
Allow crunchy, chewy, or spicy snack breaks, (e.g., pretzels, dry cereal, fruit roll ups, hot tamale candies, slim jims,
beef jerky, etc.)
If cafeteria bothers child, consider allowing him/her to eat in another location
Consider use of flavored chapstick
Intervention results:
Behavioral Response
Provide verbal warnings about changes in the schedule
Provide visual schedule
Help students transition between activities using timers, music or transitional objects, such as using a book to bridge
to library time, or a marker to bridge to art time
Provide a quiet space for calming away from peers NOT THE TIME-OUT AREA
For lethargic students, increase movement opportunities, incorporate multi-sensory experiences, and spicy/crunchy
snacks
Intervention results:
18
Date Intervention
Ends
MOTOR SCREENING
Student’s Name: _____________________________________
Date of Birth: _____/_____/_____
Page 1 of 2
Age: ____ Grade: ________ School:______________________________
Completed by the student’s Physical Education Teacher: ____________________________________________________
_____/_____/_____
Signature
Date
SBLC pre-referral/initial
interim
Change of Exceptionality
Other:_________________________________________________________________________________
Complete only items for appropriate age level
Scoring Code:
+ Symbol=Successfully Completed
o Symbol=Unable to Perform
If student is unable to perform 3 or more items in age level then student is at risk.
SCORE
PERFORMANCE STANDARD
Age 3
Age 4
Age5
Stationery
ball
Rolling ball
Kick a 7-inch playground ball
Catch a bean bag tossed from a
distance of 5 feet (3 attempts)
Traps to
body
Walk on a line (3 inches broad)
without stepping off
SCORE
PERFORMANCE STANDARD
Age 9
Age 10
Age 11
Run to & Kick
Rolling ball
Perform bent-knee crunches
13 times
15 times
16 times
Catch with
both hands
Catch with one
hand
Perform standing long jump
3’4”
3’8”
4’0”
5 steps
towards
10 steps
towards
514
steps
backward
Perform AAHPER shuttle run
13.0 sec
12.8 sec
12.4 sec
Get up from floor without
assistance
Sitting using
hands
Sitting w/o
hand support
Lying w/o
hand support
Throw a basketball to a wall and catch the
rebound from a 4 foot restraining line for 15
seconds
6 times
7 times
8 times
10 steps
15 steps
3 feet
5 feet
10 feet
Walk forward on a line alternating feet
touching heel to toe
5 steps
Throw a small ball overhead
SCORE
PERFORMANCE STANDARD
Age 6
Age 7
Age 8
SCORE
Age 12
PERFORMANCE STANDARD
Age 13
Age 14
Age 15 &
Older
Hop on preferred foot
5 times
10 times
15 times
Perform bent-knee crunches
20 times
20 times
20 times
20 times
Skip forward, alternating feet
5times
10 times
15 times
Perform standing long jump
4’0”
4’0”
4’0”
4’0”
5 times
10 times
15 times
12.2 sec
12.2 sec
12.1 sec
Boys 12.0 sec
Girls 12.6 sec
5 times
6 times
7 times
8 times
Dribble ball with preferred hand
Catch a bean bag tossed from ate
appropriate distance with one hand
(3attempts)
Perform AAHPER shuttle run
6 feet
10 feet
12 feet
Throw a basketball to a wall and catch
the rebound from a 4 foot restraining
line for 15 seconds
4 sec.
8 sec.
8 sec.
Walk backward on a line alternating feet 5 steps
10 steps
10 steps
10 steps
Balance on one foot
touching heel to toe
Is student participating successfully in regular physical education activities? ________ if not, why not? ____________________________________________________________
Over
19
PAGE 2 OF 2
Check all that apply
Completed by:
_____
(Referring Teacher / IEP Teacher signature)
GROSS MOTOR
Limited movement of arms and/or legs
Wears/uses special equipment:
crutches
braces
walker
splint
wheelchair
other_________________
Poor balance:
standing
walking
using stairs
Poor movement control
Trembles
Tires easily
Requires physical assistance (describe):
_____/_____/_____
(Date)
FINE MOTOR / PERCEPTUAL
 Attach written work samples
Poor motor control:
Avoidance of paper-pencil tasks
drawing
coloring
cutting
copying
Handedness undetermined
Left handed
Right handed
Pencil grasp:
w/fist
w/fingers
Pencil strokes:
heavy
light
Hand trembles during fine-motor tasks
Letter formation:
uneven spacing
poor formation
reversals
Unable to complete written work during assigned time due to:
inattention
poor motor skills
slow speed
inaccurate spelling
Other:
SELF-HELP
Appears stiff tense and/or weak
Bone Deformities
Trips or falls often
CHECK ALL THAT APPLY:
Lack of strength
Lack of endurance
Lack of
flexibility
Failure to show opposition of limbs when walking, sitting, or throwing
Ability to produce legible written communication
Difficulty with balance activities
Lack of control with ball skills
Poor sense of body awareness
Difficulty in crossing the vertical midline
Difficulty in remembering motor sequences
Drools
Requires help with:
dressing
undressing
Feeding
needs special equipment
unable to chew
excessive spillage
Needs assistance with toileting (explain)
Teacher Comments:
Submit completed form to: Name:__________________________________________________________________________
RTI/SBLC Chairperson
IEP Teacher/IS
PA Representative
OT/PT/APE Staff Comments: ____________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
Reviewed By:__________________________________________________
Signature
_____/_____/_____
APE
OT
PT
Date
Reviewed By:__________________________________________________
Signature
_____/_____/_____
Date
APE
OT
PT
Reviewed By:__________________________________________________
Signature
_____/_____/_____
Date
APE
OT
PT
SBLC/IEP DECISION: The motor screening was reviewed on _____/_____/_____ and an
(Date of SBLC or IEP meeting)
OT
PT
20
APE evaluation
was
was not recommended.
Revised 7-1-15
HEALTH SERVICES SCREENING FORM
Screening
Student_____________________________________________ DOB_____________ Grade _____ Date _____
_____
SDT# _______________________ School ________________________________ Is the student homebound? ____Yes _____No
Parent(s)___________________________________ Home Phone___________________ Alternate Number _________________
Form completed by
CPSB Employee Signature
Position ___________________
Return to ___________________________________________________________ By (date of IEP/Re-eval) __________________
Reason:
Preschool Clinic
SBLC/Initial
Interim IEP
Annual IEP
Respond YES or NO to items 1 - 11 below:
DOES THE STUDENT
A. Description of Medical Need, Diagnosis or Treatment
1. Experience severe allergic reactions that require immediate medications,
i.e., Epi-Pen? Drug allergies: ___________________________________
YES
NO
Re-eval
Re-eval New Concern
COMMENTS
(Explain in detail all YES responses)
2. Have a current medical diagnosis (i.e., diabetes, tuberculosis, ADD,
seizures, cystic fibrosis, asthma, muscular dystrophy, liver disease,
digestive disorders, respiratory disorders, hemophilia)?
Condition: _________________________________
Diagnosis:
3. Receive medical treatments during or outside the school day (i.e.,
oxygen, gastrostomy care, tracheostomy care, suctioning, injections,
insulin pump)?Condition:___________________________
4. Experience frequent absences due to illness or frequent hospitalizations?
Treatment:
5. Receive ongoing prescribed medication at home or school for physical or
emotional problems (i.e., seizure, heart condition, allergy, asthma, cancer,
depression, ADHD)?
Medication:
Physician:
Physician:
Physician:
Hospital:
Medication is dispensed: __at home __at school
B. Environmental Adjustments Required Within the Educational Setting
6. Require adjustments of the school environment or schedule due to a
health condition (i.e., seizures, limitations in physical activity, periodic
breaks for endurance, part-time schedule, building modifications for
access)?
7. Require environmental adjustments to classroom or school facilities (i.e.,
temperature control, refrigeration/ medication storage, availability of
running water, wheelchair accessibility)?
8. Require major safety considerations (i.e., special precautions in lifting,
positioning, special transportation, emergency plan, special safety
equipment, special techniques for positioning, feeding)?
9. Require an emergency plan (Consider: seizure disorders, diabetes,
asthma, and severe allergic reactions)?
10. Requires a physician prescribed special diet (i.e., blended, soft, low salt,
low fat, liquid supplement, food allergies)?
C. Assistance/Modifications Required for Activities of Daily Living
11. Require assistance with activities of daily living (i.e., eating, toileting,
walking, diapering)?
HEARING
Yes
No
VISION
-history of acute ear infections?
-history of acute eye infections?
-history of chronic ear infections?
-history of chronic eye infections?
-persistent head colds?
To receive a Health Services Assessment, there must be a check in the yes
column in any section.
Asthma, diabetes, seizures always require an emergency health plan.
Does student require a health services assessment?
yes
WHITE COPY to nurse with current medicals attached
PINK COPY to IEP Folder
YELLOW COPY to PA records Instruction (if Exceptional student)
21
no
Yes
No
Revised 7-1-15
LOUISIANA ASSISTIVE TECHNOLOGY SCREENING for SCHOOL AGE STUDENTS
Checklist for Use in Educational Programming
Student's Name: ______________________________ DOB: ____________ Screening Date: _______________
Person Completing Form: ____________________________ School: _________________________________
The Assistive Technology Screening Checklist documents physical, fine/gross motor, communication, sensory,
academic, recreation and leisure, vocational, and self-help areas in which assistive technology may be considered to
enable a student with a disability to access the general education curriculum. It serves as an organizer for considering
those skills and activities in which assistive technology would benefit a student's functioning in an academic setting.
Directions: Check yes or no for the following statements.
Physical Functioning/Motor Abilities
Task
1. The student can sit upright while completing tasks at
his/her desk (i.e., not slouched, can hold head
upright).
2. The student maintains an appropriate posture while
seated and actively engaged in a motor task (i.e.,
keyboarding, cutting).
3. The student participates in playing and running
activities without atypical postures.
4. The student sits on the floor without assuming
asymmetrical postures.
5. The student has the motor skills necessary to get
to/from school and/or get around within the school.
6. The student participates in physical activities
(structured or independent) and navigates within the
classroom without tripping and stumbling.
7. The student climbs and descends stairs
independently.
8. The student is able to open doors independently.
9. The student maintains balance while performing an
activity (e.g. getting up from the floor).
10.The student carries objects while walking
independently (e.g. books and papers).
Comments:
Yes
No
Comment
Yes
No
Comment
Fine Motor Skills
Task
1. The student cuts and/or handles scissors
independently.
2. The student uses writing utensils (i.e. markers,
paintbrush, pencil, crayons) independently.
3. The student copies materials from a book.
4. The student turns pages in a book.
5. The student ties shoes, buttons, snaps, and/or uses
zippers independently.
6. The student operates door handles, water faucets
and uses manipulatives.
7. The student uses a standard keyboard to access a
computer.
8. The student draws, forms letters, stays on the line,
and/or traces accurately with writing utensils.
(over)
22
Communication Functioning
Task
1. The student speaks to communicate. (Check the
level of the communication development.)
a.
Fluent Conversation
b.
Multiword Phrases
c.
Single Word Utterances
d.
Vocalizations
e.
Other
2. The student uses a mode other than speech to
communicate. (Check the communication mode.)
f.
Mode(s) used
g.
Fluent Conversation
h.
Multiword Phrases
i.
Vocalizations
j.
Other
3. The student responds to speech and noises in the
environment.
4. The student's mode of communication is understood
by others.
Comments:
Yes
No
Comment
Yes
No
Comment
Yes
No
Comment
Vision/Hearing
Task
1. The student is able to see printed materials
presented in the classroom.
2. The student is able to see toys/objects in the
classroom environment.
3. The student is able to transfer information from a
book, chart, and/or chalkboard to paper.
4. The student has some usable vision.
5. The student has some usable hearing.
6. The student is able to hear speech/noise out of
his/her field of vision.
7. The student responds best to speech when the
stimulus is within six feet of the speaker.
8. The student speaks in an unusually loud voice.
Comments:
Academic Functioning
Task
1. The student understands basic cause/effect.
2. The student makes choices.
3. The student has the age-appropriate attention span
needed to handle school/daily living tasks.
4. The student has sequencing skills.
5. The student can remember the steps necessary to
accomplish a task.
6. The student visually tracks along a line of print.
7. The student reads text independently.
8. The student writes legibly.
9. The student writes legibly at a reasonable rate.
23
Academic Functioning (Cont'd)
10. The student accomplishes written tasks (e.g.,
paragraphs, essays, short answers).
11. The student correctly spells words needed to
communicate in written form.
12. The student performs mathematical tasks needed
for school and/or for daily living.
13. The student takes notes at the level needed in school
and/or in daily living.
Comments:
Recreation and Leisure
Task
1. The student uses the playground equipment
independently.
2. The student participates in group recreational
activities, such as sports and group games.
3. The student participates in activities requiring fine
motor skills, such as board games or art.
4. The student participates in extra-curricular activities,
such as clubs.
Comments:
Yes
No
Comment
Yes
No
Comment
Yes
No
Comment
Vocational Functioning
Task
1. The student demonstrates sufficient stamina to work
in a job.
2. The student maintains a position for extended periods
of time.
3. The student uses a computer without modifications.
4. The student holds the telephone and dials
independently.
5. The student independently uses equipment at a
vocational training program.
Comments:
General Health
Task
1. The student breathes without difficulty.
2. The student demonstrates sufficient stamina to
maintain academic involvement throughout the school
day.
3. The student independently uses stairs, elevators,
lockers, etc. within the school/work/community
environment.
4. The student's health condition is adequate for
satisfactory school performance.
5. The student demonstrates physical strength needed
to participate in school activities.
Comments:
(over)
24
Self-Help
Task
1. The student independently uses a variety of clothing
fasteners.
2. The student organizes and maintains his/her school
supplies and materials.
3. The student independently files through a lunch line,
selects meal items, and proceeds to a table.
4. The student maintains personal hygiene.
5. The student uses restrooms independently.
6. The student manages meal-time utensils adequately.
Comments:
Yes
No
Comment
Summary of Results of Louisiana Assistive Technology Screening Checklist for Use In Educational
Programming: Examine areas on the screening where student has received no responses. Review and
determine if a referral for further assessment is necessary.
Recommendations: (Check the one statement that applies.)
___ 1. Student has been considered for assistive technology and further action is not required at this
time.
___ 2. Student has been considered for assistive technology and additional screening in the following
areas is recommended: _______________________________________________________
___ 3. Student has been considered for assistive technology and the following "low-tech" solutions are
recommended: ______________________________________________________________
___ 4. Student has been screened for assistive technology and a referral for a full assistive technology
assessment is recommended.
Action Taken:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________
PA COORDINATOR SIGNATURE
____________________________
DATE
25
CADDO PARISH SCHOOLS
FUNCTIONAL BEHAVIORAL ASSESSMENT
(FBA) Overview
The Functional Behavioral Assessment (FBA) is a process for gathering and recording information that can be used to
develop a hypothesis about why behavior occurs or recurs. FBA should be the starting point for Tier-2 interventions and
must be conducted prior to the development of an individualized Behavior Intervention Plan. FBA process must be
completed at each Manifestation Determination Review (MDR).
The FBA process involves these five components:
 Define the problem in clear, observable terms so it is recognizable to everyone. This is called the “Behavior of
Concern”.
 Identify specific events, times, and situations about this behavior to look for patterns that will indicate what appears
to set off the problem behavior. Answer key questions such as: Who is there when the behavior occurs? What is
going on at the time? When and where does it happen?
 Gather background information from teacher and parents to consider medical, physical, and social concerns. Some
of these issues may surface as causal factors.
 Identify the consequences that might be maintaining the behavior.
 Develop a hypothesis about the purpose (function) of the behavior.
The table below describes each of the forms included in the FBA:
WHAT
Baseline Data Forms
WHEN
a) Baseline Data is used to
record behavior(s) for 3
weeks, when there is an
initial concern
RESULT
a) Data sheet of behavior(s) of concern
indicating a pattern and frequency of
occurrence
b) Baseline Data is used to
record behavior(s) during
implementation of Tier 2 /
Tier 3 interventions.
b) Data sheet of behavior(s) of concern
to monitor the decrease or increase of
the frequency of the undesired
behavior(s)
Record daily whenever
behaviors occur
Log sheet of behavior(s) of concern,
which indicate patterns and strategies
FBA2
Student Interview
Teacher(s) who observes
behavior(s) of concern. All
teachers of student must
complete.
Case manager or any team
member will interview student
When FBA is conducted,
prior to development of BIP
Indicates student’s perception of
his/her behaviors at school
FBA3
Parent/Guardian
Interview
Case manager or any team
member will interview parent
to gather concerns
When FBA is conducted,
prior to development of BIP
Indicates parent/guardian concerns,
medical update, family support, etc.
FBA1
Anecdotal Record
WHO
All Teacher(s) who teach
student (Including core
teachers/enrichment teachers,
etc.)
FBA4
Teacher Interview
All contact teachers/staff of
When FBA is conducted,
Indicates each teacher / staff
student (include
prior to development of BIP
perspective and possible function(s) of
administrators,
behavior
paraprofessionals, bus
drivers, etc.) who work with
student
FBA5
RTI/SBLC/IEP team conducts Prior to development of
a) Must have a hypothesis that will
Summary of Findings
summary at meeting. BIS will individualized BIP
drive the choice of strategies used on
analyze Summary Statement
BIP
and Support staff will
facilitate completion of this
form
* NOTE: Case Managers must be invited to attend RTI/SBLC meetings and informed of duties and responsibilities for implementing
and collecting FBA data.
(RTI/SBLC/IEP Team shall complete the Parental Permission FBA form each school year before beginning
the FBA process. This process must also be completed for the Emergency Behavior Plans before beginning
the FBA process).
26
Procedures for Developing Initial Behavior Intervention Plans
(Students with Disability)
1st Teacher/Administrator notifies IEP Teacher/Lead Teacher/Behavior Intervention Specialist through
referral process (verbal/email/BIS-1 Referral Form).
2nd
IEP teacher provides all student’s teachers a copy of FBA-1 Anecdotal Records and
Baseline Data Form. Information will be documented consequently for 3 weeks by each teacher noting
behavior(s) of concerns with student. IEP Teacher will e-mail PA Coordinator, IS/Lead Teacher, and
Behavior Intervention Specialist to inform of initiated process.
3rd The PA Coordinator or Behavior Intervention Specialist will observe the student during the 3-week
period. Observations will be documented on the Student Behavior Observation Form.
4th
An IEP conference should be scheduled at the beginning of the 4 th week, by the IEP Teacher inviting
the Instructional Specialist/Lead Teacher, PA Coordinator and/or Behavior Intervention Specialist.
5th
Forms to be completed and by whom during the 3 week period include:
a) FBA2 Student Interview (IEP Teacher/any Team Member)
b) FBA3 Parent Interview
(IEP Teacher/any Team Member)
c) FBA4 Teacher Interviews (IEP Teacher distributes to all teachers who teach the student)
**Lead Teacher may assist with this process.
6th
IEP Teacher will collect all forms (within 3rd week) to give to PA Coordinator or Behavior
Intervention Specialist. IEP teacher will e-mail PA Coordinator or BIS to inform of collection of all
forms and placement in school mailboxes.
□ Baseline Data Form
□ FBA1: Anecdotal Records
□ FBA2: Student Interview
□ FBA3: Parent Interview
□ FBA4: Teacher(s) Interview(s)
PA Coordinator or BIS review all FBA data (within the 3rd week) and drafts a FBA5: Summary of
Findings for IEP meeting. (Must complete a separate summary for each behavior of concern.)
Parent Concerns and Hypothesis are completed in IEP meeting by IEP team.
7th
8th
Decision is made during IEP meeting as to need for more positive behavior support strategies to be
implemented and documented on IEP (i.e. Tier 2-strategies—Behavior Contract/Check In/Out) or if a
Behavior Intervention Plan (BIP) is needed. If a BIP is needed, interventions/supports/corrective
strategies and incentives (which specifies frequency, where, when, and by whom) are
decided by IEP Team. If a BIP is not warranted, FBA5: Summary of Findings will be signed and
the GSI page of the IEP under Behavior will be documented for strategies to be implemented and
monitoring process for strategies / supports.
9th
Crisis Management Plan is needed if the student is and has potential of becoming physically
and/or verbally aggressive. (Verbal aggression is defined as a loud continuous use of profanity and
threatening harm to themselves and/or others.)
10th
If BIP/Crisis Plan is needed, IEP Teacher/Lead Teacher is responsible for distributing and
collecting BIP/Crisis Plan/Monthly Progress Reports/Baseline Data/ and any other supporting
documentation to all teachers/staff of student. IEP teacher, Instructional Specialist/Lead Teacher,
and Behavior Intervention Specialist will check for completion of Monthly Progress Reports from all
teachers/staff. If teachers/staff are having problems completing forms correctly, team member will
provide support. Monthly Progress Reports are signed by student and teacher. IEP Teacher will
collect all Monthly Progress Reports by 5th day of following month. BIS/Related -Service Provider
will review/initial, date and return to IEP teacher to maintain in red discipline folder.
11th
Monthly Progress Reports are completed daily by all teachers/staff of student. Baseline Data Form is
completed (collect data for two weeks) by all teachers/staff at least 3 weeks prior to IEP
annual date in to updated BIP. FBA1: Anecdotal Record and Monthly Progress Reports must
continue to be completed as required.
27
Procedures for Existing Behavior Intervention Plans
(Students with Disability)
1st
IEP teacher provides all students’ teacher(s) a copy of the FBA-1: Anecdotal Records,
Monthly Progress Report and copy of Behavior Intervention Plan. IEP teacher will fill
in Replacement Behaviors from BIP, before distributing Monthly Progress Report to all
teachers. All replacement behaviors should be positively stated and measurable.
2nd
IEP Teacher will collect all Monthly Progress Reports monthly from all teachers. Each Monthly
Progress Report should be completed (points totaled, percentage calculated, IEP goal displayed,
and any incentives provided, by whom and when).
3rd
When student reaches 4th day of out-of-school suspension, IEP Teacher is responsible for
ensuring the following information is completed: Student and parent are always interviewed by
IEP teacher or team members.
a) FBA-2 Student Interview (IEP Teacher / any team member)
b) FBA-3 Parent Interview (IEP Teacher / any team member)
c) FBA-4 Teacher Interviews (IEP Teacher distributes to all teachers who teach student)
4th
IEP meetings are reconvened on 4th, 7th, and 10th day of out-of-school suspension. Document all
additional strategies and supports and revisions made to the Behavior Intervention Plan.
5th
IEP Teacher and Instructional Specialist / Lead Teacher are responsible for arranging IEP meetings
and ensuring the PA Coordinator or Behavior Intervention Specialist, if assigned, are informed of all
scheduled meetings. IEP conferences should be scheduled on a day support staff is already
scheduled to be at the school if possible.
6th
Baseline Data is completed 3-weeks prior to student’s annual IEP meeting. For the time period
this form is being completed, FBA-1: Anecdotal Record and Monthly Progress Report must
continue to be completed as required.
7th
Baseline Data forms are collected by IEP Teacher and provided to PA Coordinator or BIS
(Related- Services Case Manager).
8th
IEP Teacher, Instructional Specialist / Lead Teacher, and BIS will check for completion of Monthly
Progress Reports by all teachers. If the teachers are having problems completing form correctly, a
team member will provide support for teacher. (Team effort)
***IMPORTANT NOTES***
1.
For zeros documented on Monthly Progress Report there MUST be documentation on Anecdotal
Record written for negative behavior. (Ensure strategies listed that are utilized by teachers are
strategies from BIP and IEP.)
2.
Monthly Progress Reports MUST be completed (points earned, percentage of points, BIP goals and incentives
including who will give the incentives.)
3.
Behaviors of Concern (list ALL behaviors of concern; however, only 2-behaviors will be targeted for replacement.)
4.
Replacement behaviors (Be specific with replacement behaviors. These behaviors SHOULD match some of the
behaviors of concern.) DO NOT use “Comply with school rules” or any other general/broad terminology as a
replacement behavior.
28
Procedures for Developing Initial Behavior Intervention Plans
(Regular Education Students)
1st
RTI/SBLC team begins the Baseline Monitoring and Functional Behavior Assessment process and
notifies all necessary team members. At the initial RTI/SBLC meeting – the Case Manager should be
designated and informed of duties and responsibilities of distributing, collecting and maintaining data.
2nd
Case Manager provides all student’s teachers a copy of FBA-1 Anecdotal Records and
Baseline Data Form. Information will be documented consequently for 3 weeks by each teacher noting
behavior(s) of concerns with student.
3rd The PA Coordinator, Behavior Intervention Specialist or School Counselor will observe the student
during 2-week period. Observations will be documented on the Student Behavior Observation Form.
4th
RTI/SBLC meeting should be scheduled at the beginning of 4 th week by Case Manager – inviting PA
Coordinator, Behavior Intervention Specialist, School Counselor and any other relevant team
members.
5th
Forms to be completed and by whom during the 2-week period include:
a) FBA2 Student Interview (Case Manager/any Team Member)
b) FBA3 Parent Interview
(Case Manager/any Team Member)
c) FBA4 Teacher Interviews (Case Manager distributes to all teachers who teach student)
**Other members of RTI/SBLC may assist with this process.
6th
Case Manager will collect all forms (within 3rd week) to give to Behavior Intervention Specialist. Case
Manager will e-mail BIS to inform of collection of all forms and placement in school mailboxes.
□ Baseline Data Form
□ FBA1: Anecdotal Records
□ FBA2: Student Interview
□ FBA3: Parent Interview
□ FBA4: Teacher(s) Interview(s)
7th
Case Manager and/or Behavior Intervention Specialist reviews all FBA data (within the 3rd week) and
drafts a FBA5: Summary of Findings for RTI/SBLC meeting. (Must complete a separate summary
for each behavior of concern.) Parent Concerns and Hypothesis are completed at RTI/SBLC
meeting by RTI/SBLC team.
8th
Decision is made during RTI/SBLC meeting as to need for more positive behavior support strategies
to be implemented and documented as required (i.e. Tier 2-strategies—Behavior Contract/Check
In/Out) or if a Behavior Intervention Plan (BIP) is needed. If a BIP is needed,
interventions/supports/corrective strategies and incentives (which specifies frequency, where, when,
and by whom) are decided by RTI/SBLC Team. If a BIP is not warranted, FBA5: Summary of
Findings will be signed and RTI/SBLC notes will be documented for strategies to be implemented and
monitoring process for strategies / supports.
9th
Crisis Management Plan is needed if the student is and has potential of becoming physically
and/or verbally aggressive. (Verbal aggression is defined as a loud continuous use of profanity and
threatening harm to themselves and/or others.)
10th
If BIP/Crisis Plan is needed, Case Manager is responsible for distributing and collection BIP/Crisis
Plan/Monthly Progress Reports/Baseline Data/ and any other supporting documentation for
BIP/Crisis Plan to all teachers/staff of student. Case Manager and/or Behavior Intervention Specialist
will check for completion of Monthly Progress Reports from all teachers/staff. If teachers/staff
are having problems completing forms correctly, team member will provide support. Monthly
Progress Reports are signed by student and teacher. Case Manager will collect all Monthly Progress
Reports by 5th day of following month. Behavior Intervention Specialist or Case Manger will review,
initial and date progress monitoring and maintain all documentation in RTI/SBLC folder.
29
July 2015
CADDO PARISH SCHOOLS
Baseline Data
Tier 2 – Tier 3
Student: _______________
Student #: ____________Teacher: _________________
School: ________________
Period: _______________ Subject Area: _____________
Grade: ______________________
Regular
Special Education
Targeted Behavior of Concern #1: __________________________________________________________
Targeted Behavior of Concern #2: __________________________________________________________
Directions: This table measures the DAILY occurrence of the behavior of concern. Place a slash through a number each time the
behavior occurs. The final number that has been slashed should be placed on the total line and percentage should be calculated and
recorded in the Total/Percentage Box.
DAY/DATE
WEEKLY FREQUENCY BOX
TOTAL/PERCENTAGE
Mon_________
Behavior #1: 0 1 2 3 4 5 6 7 8 9 10
Behavior #2: 0 1 2 3 4 5 6 7 8 9 10
___out of 10
___out of 10
Tues_________
Behavior #1: 0 1 2 3 4 5 6 7 8 9 10
Behavior #2: 0 1 2 3 4 5 6 7 8 9 10
___out of 10
___out of 10
Wed_________
Behavior #1: 0 1 2 3 4 5 6 7 8 9 10
Behavior #2: 0 1 2 3 4 5 6 7 8 9 10
___out of 10
___out of 10
Thurs________
Behavior #1: 0 1 2 3 4 5 6 7 8 9 10
Behavior #2: 0 1 2 3 4 5 6 7 8 9 10
___out of 10
___out of 10
Fri__________
Behavior #1: 0 1 2 3 4 5 6 7 8 9 10
Behavior #2: 0 1 2 3 4 5 6 7 8 9 10
___out of 10
___out of 10
Total Average %: Behavior #1_______________ Behavior #2__________________
Baseline Data: Behavior #1 and #2
Frequency
10
8
6
4
2
0
Day 1
Day 2
Day 3
Day 4
Day 5
Teacher Signature: _________________________
Comments: _____________________________________________________________________________________________
________________________________________________________________________________________________________
Related Services Cases are monitored by Related Service Providers. Non -Related Services Cases are monitored by
the Behavior Intervention Specialists/SBLC Team Member.
30
July 2015
CADDO PARISH SCHOOLS
ANECDOTAL RECORD
BEHAVIOR ASSESSMENT (FBA1)
(Frequently Asked Questions)
STUDENT: ____________________________
TEACHER: _________________________
Date /
Time
Setting
Specifics as to
Where/When & Who
was involved
STUDENT NUMBER: ______________
GRADE: ________
SCHOOL: ______________________
SUBJECT/CLASS: _____________________ START DATE: ________
Describe what
happened immediately
before Behavior(s)
occurred
Behavior(s) of Concern
Describe what it looks like?
nonjudgmental, observable terms,
clearly defined
31
Regular
Outcome /
Consequences
Describe how you and
others responded after
behavior(s) occurred
Special Education
List Positive
Strategies Used
Tier I, Tier II
or as identified on
Behavior Intervention
Plan
July 2015
Caddo Parish Public Schools
FUNCTIONAL BEHAVIOR ASSESSMENT
Student Interview (FBA2)
Student: _____________________________ Student #: _______________ School: _______________ Grade: _____
Interviewer: ___________________________ Position: _____________________________ Date: ________________
Directions: Complete interview with student. Document all student responses on interview form. Signature of interviewer
is required.
STUDENT PROFILE
What are some things you like / dislike at school, home, and other places? _______________________________________________
___________________________________________________________________________________________________________
Do you find your teachers/classes encourage you to be on task? ________________________________________________________
What subjects or classes you like most or least? Why? _______________________________________________________________
___________________________________________________________________________________________________________
DESCRIPTION OF BEHAVIOR
Do you get in trouble at school? ________ What kind of behaviors seem to be a problem?/What are some things you do that get you
in trouble or that are a problem at school?(ex: talking out, disrespect, fighting) ___________________________________________
__________________________________________________________________________________________________________
Where do you usually get into trouble? Where do these behaviors occur? State specific parts of the school or specific class(es).
____________________________________________________________________________________________________________
Do you display/use/exhibit the same behaviors in all classes? __________________________________________________________
How often do you have problems at school?
Everyday
Couple of times a week
Couple of times a month
How do you calm yourself? _______________________________________________________
When you are upset do you feel?
□ sad □ anxious □ hurting yourself □ want to be alone
How long does it take you to get back on task after the behavior happens? (When are you ready to go back to the classroom?)
___________________________________________________________________________________________________________
Are you and other students prevented from doing what you are supposed to do? __________________________________________
SUMMARY OF ANTECEDENT
What happens to make it more likely that you will have this problem?
teachers, specific students)
(ex: difficult tasks, transitions, teacher requests, specific
____________________________________________________________________________________
____________________________________________________________________________________________________________
Is there anything that happens before or after school or in between classes that makes it more likely that you’ll have a problem?
(ex: conflict with peers, conflict @ home, lack of sleep)
____________________________________________________________________________________________________________
DESCRIPTION OF CONSEQUENCE
What usually happens after the problem occurs? (ex: teacher reaction, other student’s reactions, sent to office)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
* * * * * IDENTIFYING INCENTIVES * * * * *
What school-related items and activities are most enjoyable to you that could serve as special incentives?
____ Art Activity
___ Computer
___ Extra Free Time
____ Music
___ Other (Specify) ________________
___ Helping Teacher
32
July 2015
Caddo Parish Public Schools
FUNCTIONAL BEHAVIOR ASSESSMENT
Teacher Interview (FBA4)
Student: _____________________________________
Student #: ________________________
Grade: ___________
Teacher: _____________________________________
School: __________________________
Subject:___________
How long have you known this student? Please identify strengths/contributions presented by this student.
____________________________________________________________________________________
____________________________________________________________________________________
Current Behavior(s) of Concern:
Identify the behavior(s) of concern: ___________________________________________________________________________
________________________________________________________________________________________________________
What does this behavior(s) look like? _________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Are other students prevented from learning due to this behavior? ____________________________________________________
After the behavior(s) ends how long does it take for the student to be able to return and engage appropriately in classroom
activities? _______________________________________________________________________________________________
________________________________________________________________________________________________________
What is typically happening before the incident? Check all that apply.
Antecedent/Event
Reprimand/Correction
Independent Seat Work
Group Activity
Transition Time
Other: ___________________
Triggers
Negative Social Interaction
Request/Redirection
Lack of Attention
Challenging Task
Interruption in Routine
Denial of Request
Other:__________________
When and where does this behavior occur? Check all that apply.
Time
Location
During Transition
Class
Assembly
During Free Time
Hallway
Bus
Specific Class/Subject:_________
Cafeteria
Restroom
Time of Day: ________________
Unauthorized Area
Gym
Why is student acting out, what appears to be the purpose (function) of this behavior?
Things student obtained:
Things student avoided or escaped from:
Adult attention
Preferred activity
Demand/Request
Reprimands/Correction
Peer attention
Tangible Item
Activity/Task
Conflict
Other ______________________
Classroom Setting
Other:______________
What strategies/interventions have been implemented to address this behavior?
Change Seating
Contact Parent
Send to Office
Time Out
Reward System
Re-teach expected behaviors
Reprimand/Redirect
Loss of Privilege
Meet with Student
Referral to Counselor
33
Change Schedule
Increase Supervision
Behavior Contract
Other: ____________________
July 2015
Caddo Parish Public Schools
FUNCTIONAL BEHAVIOR ASSESSMENT
Teacher Interview (FBA4)
Student: _____________________________________
Student #: ________________________
Grade: ___________
Teacher: _____________________________________
School: __________________________
Subject:___________
How long have you known this student? Please identify strengths/contributions presented by this student.
____________________________________________________________________________________
____________________________________________________________________________________
Current Behavior(s) of Concern:
Identify the behavior(s) of concern: ___________________________________________________________________________
________________________________________________________________________________________________________
What does this behavior(s) look like? _________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Are other students prevented from learning due to this behavior? ____________________________________________________
After the behavior(s) ends how long does it take for the student to be able to return and engage appropriately in classroom
activities? _______________________________________________________________________________________________
________________________________________________________________________________________________________
What is typically happening before the incident? Check all that apply.
Antecedent/Event
Reprimand/Correction
Independent Seat Work
Group Activity
Transition Time
Other: ___________________
Triggers
Negative Social Interaction
Request/Redirection
Lack of Attention
Challenging Task
Interruption in Routine
Denial of Request
Other:__________________
When and where does this behavior occur? Check all that apply.
Time
Location
During Transition
Class
Assembly
During Free Time
Hallway
Bus
Specific Class/Subject:_________
Cafeteria
Restroom
Time of Day: ________________
Unauthorized Area
Gym
Why is student acting out, what appears to be the purpose (function) of this behavior?
Things student obtained:
Things student avoided or escaped from:
Adult attention
Preferred activity
Demand/Request
Reprimands/Correction
Peer attention
Tangible Item
Activity/Task
Conflict
Other ______________________
Classroom Setting
Other:______________
What strategies/interventions have been implemented to address this behavior?
Change Seating
Contact Parent
Send to Office
Time Out
Reward System
Re-teach expected behaviors
Reprimand/Redirect
Loss of Privilege
Meet with Student
Referral to Counselor
34
Change Schedule
Increase Supervision
Behavior Contract
Other: ____________________