Form 1 – Therapeutic Specialist
Form 9 – List of Artifacts – Social Worker
This is a listing of sample artifacts by domain component. Additional artifacts may be needed to support your professional practice.
Submit a list five days prior to Summative Conference. Bring the hard evidence to the Summative Conference.
Domain 1: Planning and Preparation
Component
Unsatisfactory
1a:
Demonstrating
knowledge and skill in
the specialist therapy
area; holding the
relevant certificate or
license
1b:
Establishing goals for
the therapy program
appropriate
to the setting and the
students served
1c:
Demonstrating
knowledge of district,
state, and federal
regulations and
guidelines
Needs Improvement
Proficient
Distinguished/Excellent
Evidence
Up to date CPDUs,
CEU
Type 73
LCSW advanced license
Artifacts
Write measurable IEP
goals
Behavior contracts
Measurable data collection
linked to FBA
BIP – explain to staff
collaborate
Artifacts
Documents consents
FBA/BIP
6 hrs legal recertification
participating in legal
committees, etc.
Artifacts/Reflection
1
Form 1 – Therapeutic Specialist
Component
Proficient
Distinguished/Excellent
1d:
Demonstrating
knowledge of
resources, both within
and beyond the school
and district
Unsatisfactory
Needs Improvement
Detailed current
contact list of agencies
Knowledge of agencies and
calendars of events
Relationship with contacts
Artifacts/Reflection
1e:
Planning the therapy
program, integrated
with the regular school
program, to meet the
needs of individual
students
1f:
Developing a plan to
evaluate the therapy
program
Established
daily/weekly schedule
to meet needs
Incorporate PBIS
The plan outlining proactive
lessons to help improve
social skills (i.e. character
ed)
Artifacts
Data collection on IEP
goals
Collaborate with admin on
data collection impacting
school improvement
Artifacts
2
Form 1 – Therapeutic Specialist
Domain 2: The Environment
Component
Unsatisfactory
2a:
Establishing rapport
with students
2b:
Organizing time
effectively
2c:
Establishing and
maintaining clear
procedures for
referrals
2d:
Establishing
standards of conduct
in the treatment center
2e:
Organizing physical
space for testing of
students and
providing therapy
Needs Improvement
Proficient
Distinguished/Excellent
Evidence
Write positive
comments
Use appropriate tone
and proper body
posture
Provide adm a
schedule
Organized SDS
process
Tames reports timely
MDR timelines
RTI meetings,
FBA/BIP process,
know principals &
sea’s
Know referral process
obtainable tier 2
process followed
Voice; manner of
posture
Posted expectations
Positive comments
May have products from
students
Seek input from principals
Observable
Detailed notes
Demonstrated flexibility in
emergencies
Artifact/ Observable/
Reflections
Team developed FBA/BIP
Artifacts
Students self-monitoring
1-5 point scales
Observable
Materials out available
Posters
Student work posted
Observable
3
Form 1 – Therapeutic Specialist
Domain 3: Delivery of Service
Component
Unsatisfactory
3a:
Responding to
referrals and
evaluating student
needs
3b:
Developing and
implementing
treatment plans to
maximize students’
success
3c:
Communicating with
families
Needs Improvement
Proficient
Distinguished/Excellent
Evidence
Contact logs
Follow up teacher
concerns
Service sheets
Response to office
referral
Clear measurable IEP
goals
Informal BIP
Formal Tier 2 plans
Formal BIP
Detailed SDS
Use referral details to build
proactive plan (i.e. PBIS
data)
Artifacts
BIP looks like a wrap plan
Tier 3 agency contact plan
Artifacts
Contact/message log
IEP documentation
Participation in after school
& community events linking
to mental health
Transporting to appt’s.
Comprehensive SDS Add’l
interviews providing parent
information
Artifacts
Modified data sheets
Modified intervention plans
Artifacts
3d:
Collecting
information; writing
reports
SDS
Time on task
EDC
Connors/ACTERS
MDR
3e:
Demonstrating
flexibility and
responsiveness
Updates to BIPs
(Formal/Informal)
Changes to goals
Changes to schedule
4
Artifacts
Form 1 – Therapeutic Specialist
Domain 4: Professional Responsibilities
Component
Unsatisfactory
Proficient
Distinguished/Excellent
Evidence
4a:
Reflecting on practice
4b:
Collaborating with
teachers and
administrators
Needs Improvement
Individual goals of
professional practice
Emails
Observable
Contacts
Individual goals of
professional practice
Demonstrating asking for
perspectives
Artifacts (form 2)
4c:
Maintaining an
effective datamanagement system
Progress report
document
Chart/graph
Understandable by parents
Artifacts
4d:
Participating in a
professional
community
Open house
Social work meets
PLC committee
Committee work districts
Lead school PLC
State Committee
Observable; Artifacts;
Reflection
4e:
Engaging in
professional
development
Keeping up with
CEU’s, CPDUs
Presenting in-services
De-escalation
Supervising intern
Artifacts; Observable
4f:
Showing
professionalism,
including integrity,
advocacy, and
maintaining
confidentiality
Attendance
Other…
Takes a lead
Observable;
Attendance Records
Reflection
5
Observable