Application and Readiness Checklist to become
Wisconsin Pyramid Model program-wide implementation site
Program-wide adoption of the Pyramid Model refers to a systemic effort within a program for Pyramid Model
implementation fidelity. It is the most effective way to change practice and support social and emotional development
of children in your program. Program-wide adoption uses a systems change model. A program leadership team guides
the implementation process to develop the supports and infrastructure needed for Pyramid Model adoption within the
classrooms and services provided to children and their families. Program-wide adoption ensures that programs are
focusing on both the adoption of evidence-based practices and the development of the infrastructure to support the
sustainable implementation of those practices. This level of implementation takes a great deal of commitment, time,
effort and resources. Programs should consider implementation as a multi-year ongoing improvement process.
Programs selected to become WI Pyramid Model Implementation sites will send their leadership team to attend
Pyramid Model Implementation Academy. The Implementation Academy will be held in Oconomowoc on November
16th- November 19th, 2015. There is a registration fee to attend this Academy. Some programs may incur overnight
travel expenses to attend the Academy. The leadership team needs to attend a two-day meeting on November 18th
and November 19th; internal coach(s) should attend all four days. The goal of the academy is to support and prepare
teams for planful implementation of the Pyramid Model in their programs. Selected programs will receive specific
information about the academy. Programs will be selected by an application review committee and notified on
October 15th, 2015.
Application due date: October 1st, 2015
Programs must complete the following readiness checklist as part of the application to be considered a Pyramid Model
implementation site and to attend the Implementation Academy. This checklist process is designed as a tool for selfreflection for programs to make informed decisions about participation. Please note that by checking a box next to an
item you indicate your program’s commitment to that element/part of the application. An application review
committee will score the application to determine your program’s readiness. Programs are asked to submit evidence
for their ratings so that the application review committee is able to assess program’s readiness and offer feedback.
The Wisconsin Pyramid Model project has found that program’s readiness is very important to successful
implementation of the Pyramid Model.
1|Page Program -wide implementation site application
Program description:
Please provide a short description of your program (program type, services provided, families served, number of
buildings or classrooms, etc.)
Program information:
Program Name:
Contact Name:
Contact Title:
Contact email:
Contact phone number:
Address:
County:
Number of children attending the program:
Age range of children served by the program:
Average annual number of children with IFSPs? __
Average annual number of children with IEPs? Approx. __
Number of classrooms?
Number of classroom staff?
Total number of staff members employed by the
program (including food services, custodial,
secretarial, administrative):____
Number of families in your program who use WI SHARES or
free/reduced lunch (if applicable) _____
1. Staff professional development readiness
Training is an important readiness component for the implementation. Staff participation in the Pyramid Model
training prior to becoming an implementation site is a requirement. This allows for staff to make an informed
decision about participating, as well as eliminates the need for the program to focus on initial training in the
first year of the implementation.
2|Page Program -wide implementation site application
Please indicate any training staff received on the Pyramid Model content
Training date and
Training Name/Title
number of hours
Trainer
Number of
staff trained
List percentage of staff members who have attended a minimum of 15 hours or more on the Wisconsin Model
Early Learning Standards (WMELS):
2. Staff willingness to participate in program-wide implementation of the Pyramid Model
Please ask all staff members to watch the short 9-minute presentation at this link:
https://www.youtube.com/watch?v=e1PjMLdw6N8 . The video describes the essence of program-wide
implementation. Consider doing this at a staff meeting. After viewing the presentation, please poll all program
staff using the paper/pencil survey available for download here: https://app.box.com/s/ik17zrma5jy74f73cd97.
We recommend that at least 80% of the entire program staff affirm their willingness to participate in the
program wide implementation, which means that they are agreeing to be supported via coaching and
observation, examine and change their practices as necessary, and review and use data in their decision making
process.
Total number of staff members in your program ___
How many staff members did you poll __
Please, list the number of staff who responded “yes” to the following questions:
1.
2.
3.
4.
I am interested and willing to participate in the program wide implementation __
I like the idea of program wide implementation, but want more training first __
I like the idea of program wide implementation, but am not ready to commit __
I don’t think that program wide implementation would be beneficial to me and/or the program __
Please indicate the percentage of all staff interested and willing to participate in the program-wide
implementation of the Pyramid Model (number of people who responded “yes” to statements “1” or “2”) ___
3|Page Program -wide implementation site application
3. Program Leadership Team
The program leadership team must include an administrator/program director, an individual who is willing to
serve as a data coordinator, teacher representative(s), the internal coach, and/or a person knowledgeable about
behaviors and/or mental health. Programs are encouraged to think critically about the number of members of
this team. It is important that this team be representational of program staff while remaining concise enough to
make decisions about implementation. Team members will solicit input/feedback from the staff when making
implementation decisions as guided by the data. Consider if your program is able to create and sustain a program
leadership team to guide and use shared decision making about implementation.
Name
Pyramid Model Program Leadership team
Role*
Agency
Number of
years
associated
with the
program
Administrator-Principal-Director
(required)
Internal coach*
Behavior Specialist*
Teacher representative
Teacher representative
Data coordinators *
External coach
* Certain roles could be served by the same person if time allocation and experience/skill allow
 Internal Coach
The internal coach is associated with the program and provides technical assistance to staff who work directly
with children and families in implementing practices and strategies.
_ _Identify and acknowledge time commitment for an internal coach. The amount of time commitment for the
internal coach varies with the scope of program implementation. At minimum, an internal coach spends 5 hours of
observation per lead teacher per year (2.5 hrs. baseline; 2.5 hrs. 6 months after the first observation) collecting
TPOT/TPITOS data plus approximately 45 min/month per teacher in coaching sessions, prep work for action
planning, individual teacher support, and other professional development activities. Internal coach will provide
technical assistance to individual teachers/providers through evidence based coaching strategies.
Internal coach will attend the two day TPOT (Teaching Pyramid Observation Tool) Reliability Training held on Nov
16th and Nov 17th and then join the program leadership team for the Team meeting on Nov 18th and Nov 19th,
2015.
The internal coach will be supported by an external coach. The internal coach may also serve as the behavior
specialist.
4|Page Program -wide implementation site application
List experience and qualifications of internal coach in coaching and mentoring. Please indicate what Pyramid
Model training the internal coach received and the experience the internal coach has in applying Pyramid Model
content.
 Data Coordinator
Collecting, reviewing and using data is an important component of the implementation. Data coordinator
oversees data collection on program, teacher, and child levels. Data coordinator submits data to the state
coordinators two times a year. Data coordinator reviews and reports data at least monthly for team leadership
meetings. It is helpful, but not necessary, if the data coordinator has some familiarity with Excel spreadsheets.
_ _Identify and acknowledge time commitment for data coordinator. Data coordinators will be supported by
an external coach and state coordinators through regular webinars.

External Coach
Programs need on-site coaching support particularly in the first year of the implementation beyond the
training received at the Academy. The external coach is typically a member of Wisconsin Training/Technical
Assistance system who is able to support the program leadership team to collect and analyze data to
make decisions about professional development, policy alignment and action steps to implement the
Program-Wide Benchmarks of Quality.
As the Pyramid Model state coordinators, we will do our best to help you identify an external coach for your
program. Please, know that your program might incur a fee associated with having external coaching support.
5|Page Program -wide implementation site application
The external coach will access technical assistance from the Wisconsin Pyramid Model coordinators. The
External Coach will join your program leadership team for the Team Implementation meeting.
If you are able to identify an individual in your community who you believe can serve as an external
coach, please list his/her name here, and explain that person’s relationship to your program:
 Behavior Specialist
It is important that your program has access to behavioral support for children with persistent challenging
behavior through an internal person on your team, mental health consultant, or behavior specialist. The
behavior specialist may be external to the program and is responsible for guiding team problem solving and
intervention support for children who need individualized interventions. This specialist should have experience
in function based problem solving. The behavior specialist will assist in supporting the team to gather, and
synthesize information to determine antecedent, behavior, maintaining consequence and function. The
behavior specialist will facilitate the team planning process to determine individualized prevention, intervention
and responding strategies to address challenging behavior. The behavior specialist will assist the team in
collecting data that measures a child’s progress.
Describe your access to a behavior support/mental health specialist. Please, list qualifications of the behavior
support/mental health specialist. Indicate whether and how this person is able to serve on your program
leadership team.
Other team members could include a parent (non-staff person), teacher assistant(s), and a contact person for
disabilities, mental health, family support, and/or curriculum. All members of this team will attend the two-day
Program Wide Implementation meeting (Nov 18th and 19th, 2015) and will be responsible for ensuring implementation
of the action plan developed during this meeting.
6|Page Program -wide implementation site application
4. Family Engagement
Describe your commitment to involve families in the Pyramid Model implementation. Describe how you currently
engage families in the activities, events, family education and decision making in your program:
5. Community Collaboration:
Describe how your program connects staff, families and children to programs, resources and individuals in the
Hmong Community, family resource centers, developmental screening, Early Childhood Councils) community.
(examples: Birth to 3, 4K, Head Start, Early Head Start, Tribal Programming, Spanish Community,
Describe access here:
7|Page Program -wide implementation site application
Our program is located in a community that is implementing school wide Positive Behavioral Interventions and
Supports (PBIS): _ _
6. Resource commitment:
Describe how you plan to allocate or raise funds to support implementation. Some costs to consider: time
allocation for internal coach, attending the Implementation Academy, time for data collection/entry, family events,
and monthly program leadership team meetings. Please try to be as specific as possible regarding the sources of
funding for your implementation. Consider creating and submitting your implementation budget for 2015-2016.
Bear in mind that full implementation is a 3 to 5 year process.
7. Data based decision making
_ _Indicate understanding and commitment to collect and use data at the program, teacher and child level. Data
collection tools will be provided by the WI Pyramid Model. Training in use of the tools will be provided at the
Implementation Academy. Support in collecting and analyzing the data will be provided by the external coach.
The process of collecting and analyzing the data can be individualized to complement each program’s current data
management system.
 Program level data:
i. Benchmarks of quality
 Teacher level data:
i. TPOT (Teaching Pyramid Observation Tool (ages 3-5)
ii. TPITOS (The Pyramid Infant Toddler Observation Scale (0-3).
 Child level data:
i. ASQ SE (Ages and Stages Social-Emotional)
ii. Collecting data on the level of challenging behavior throughout the program using the
Behavior Incident Report.
Our program is dedicated to and familiar with data based decision making for use at the program, teacher, and
child levels. Presently, we utilize the Benchmarks of Quality, Self-Assessment Survey (PBIS) and the ASQ SE. We
hope to learn more about the TPOT and TPITOS through training opportunities, as well as how documentation/
collection of data can be completed through our student data system, Infinite Campus.
8|Page Program -wide implementation site application
8. Describe your program curriculum and how your program monitors the development of children. Do you have
a formal way to aggregate and analyze data? How do you share information about child development with
families?
9. Describe how children with disabilities are supported in your program:
9|Page Program -wide implementation site application
10. Describe your program’s involvement with other improvement initiatives and the results. Please share your
program’s YoungStar rating (if applicable) :
Implementation Scope
There are several ways/levels of the program-wide implementation. Phased-in implementation is definitely an
option. Depending on your resources and staff you might consider implementing in several pilot classrooms. It is
fine to have pilot classrooms of same age children or varied ages.
Please indicate how many classrooms you currently intend to coach in the first year ________________
This application is submitted by:
___
(electronic signature)
Administrator’s signature
_
_
Date
Please, submit your completed application to Lana Nenide at lnenide@wiaimh.org on or before October 1st, 2015
Thank you for your interest in program wide implementation of the Pyramid Model.
Your application will be reviewed by an application review committee and your contact
person will be notified on October 15th, 2015
10 | P a g e P r o g r a m - w i d e i m p l e m e n t a t i o n s i t e a p p l i c a t i o n