2014-15 Recognized School Application - Behavior
Does your school meet the required criteria to apply?
In order to qualify to apply for the Wisconsin RtI Center's Recognized Schools the following criteria will need to
be met. Please confirm that you have met the following criteria.*
Yes
No
Does your school have an implementation team with at least 3 members and a school
decision maker? (Definition of decision maker - Principal, Assistant Principal, Dean of
Students, Director of Learning, RtI/PBIS Coordinator, Pupil Services Director, Special Ed
Director, Superintendent, Assistant Superintendent, Curriculum and Instruction Director)
()
()
Did your school's implementation team meet in at least 6 months over the past year?
()
()
Did the school decision maker (as defined above) attend at least 6 school implementation
team meetings over the past year?
()
()
Does your school have an internal or external PBIS coach identified?
()
()
Has your school's PBIS team attended the Wisconsin RtI Tier 1 (Universal level) training's
(U100, U200, U300)?
()
()
Has your school scored at fidelity (70%) on the Benchmarks of Quality (BoQ) from May 1,
2014 through present?
()
()
Has your school verified that your BoQ fidelity score is evidenced on the PBIS Assessment
website?
()
()
Does your school have and are willing to share at least 1 year of Office Disciplinary
Referral Data?
()
()
What you need to know
Congratulations, you qualify to apply for the 2014-15 Wisconsin RtI Center
Recognized Schools.
Wisconsin RtI Center Recognized School Application - Behavior (PBIS)
Applications are open from March 3, 2015 - April 29, 2015 at 5:00 pm
Tips for Success:
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Complete as much of the application as you can - you do not need to have all sections of the application well
established to receive recognition but the more detail that you can provide will substantially improve your scores.
Do NOT include student or staff level identifiable data.
Gather information/data needed to complete the application first - look at the Word version of the application to
determine what needs to be gathered.
You must enter all your data into the SurveyGizmo form during one session. You will not be able to save
what you have entered and come back to it later. To help avoid any loss of data by entering directly into
SurveyGizmo, we HIGHLY recommend completing the Word version first and then cutting and pasting
the information into the electronic SurveyGizmo form.
Reach out to us at the Wisconsin RtI Center with any technical problems as soon as you can.
For information about the Wisconsin RtI Center Recognized Schools and printable applications, please visit
the Wisconsin PBIS Network
Questions or clarifications on specific questions in application: Please contact your Wisconsin RtI Center Regional Technical
Assistance Coordinator
Technical Issues with completing the application
For any assistance regarding technical issues, please contact Melissa Marks at marksm@wisconsinpbisnetwork.org or (920)
948-5979. Applicants that experience unforeseen technical issues with the application submission software beyond their control
that prevent them from submitting their application by the deadline must e-mail Melissa Marks (contact information above)
within 24 hours after the application deadline and request approval to submit their application.
Technical Requirements: Those completing the application within a browser other than Google Chrome or Firefox,
(such as Internet Explorer), may need to download the most recent version of Adobe Flash Player. Provided here is the
most recent version of the Flash Player free download Flash Player.
Important*
[ ] I have read all the directions and I am ready to start the application for recognition
Application
Section 1: Primary Contact Information
1.) Primary Contact Person for this Application:*
Primary Contact Name: _________________________________________________
Primary Contact Phone: _________________________________________________
Primary Contact Email: _________________________________________________
Note: The primary contact person will receive a PDF of the application via email after submission. If you do not receive
the PDF please contact Melissa Marks at (920) 948-5979 or marksm@wisconsinpbisnetwork.org if you would like to
verify your submission.
Section 2: School Information:
2.) District Name* - Choose from a drop down in SurveyGizmo
2.1) School Name* - Choose from a drop down in SurveyGizmo
2.2) Grade Level of Your School*
( ) Early Childhood
( ) Pre K-12/K-12
( ) Elementary
( ) K-8
( ) 6-12
( ) Middle School/Junior High
( ) High School
2.3) Superintendent Contact Information*
Name
Superintendent*
Email
Mailing Address
2.4) Additional Contact Information:
Name
Email
Principal*
PBIS Internal Coach*
PBIS External Coach
District PBIS Coordinator
Section 3: Implementation Team Information
Please enter the name and position title of your implementation team members including your decision
maker:
(Definition of decision maker - Principal, Assistant Principal, Dean of Students, Director of Learning,
RtI/PBIS Coordinator, Pupil Services Director, Special Ed Director, Superintendent, Assistant
Superintendent, Curriculum and Instruction Director.)
3.) We require at least 3 members and a decision maker to qualify for recognition.
Name
Decision Maker*
Team Member*
Team Member*
Team Member*
Team Member
Team Member
Team Member
Team Member
Team Member
Team Member
Position Title
3.1) Please enter the dates of your implementation team meetings, and whether a decision maker attended each meeting
(from May 1, 2014 through current). Please enter N/A in any fields that there is no data. Schools must have meetings
in at least 6 months with a decision maker attending to qualify for recognition.
(Definition of decision maker - Principal, Assistant Principal, Dean of Students, Director of Learning, RtI/PBIS
Coordinator, Pupil Services Director, Special Ed Director, Superintendent, Assistant Superintendent, Curriculum and
Instruction Director)*
Date of Monthly
Team Meeting
(MM/DD)
Did a decision maker attend this
meeting?
Yes*
No*
May 2014
()
()
June 2014
()
()
July 2014
()
()
August 2014
()
()
September 2014
()
()
October 2014
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()
November 2014
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()
December 2014
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January 2015
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February 2015
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March 2015
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()
April 2015
()
()
Section 4: Training/Assessment
Wisconsin RtI Trainings and Supports - What are the dates that your school team last attended the "Developing your Tier
1 Universal System" training (U100, U200, U300)?
If you do not know the exact date of the training your team attended, please select the 1st of the correct month and year
your team had attended the training.*
4.) Date Attended (U100): - Choose from a pop up calendar in SurveyGizmo
Date Attended (U200): - Choose from a pop up calendar in SurveyGizmo
Date Attended (U300): - Choose from a pop up calendar in SurveyGizmo
4.1) Additional Wisconsin RtI Trainings and Supports - Please indicate what other Wisconsin RtI Center
trainings/activities/networkings/supports your school has participated in over the past school year (2014-15)
(check all that apply).
[ ] Academic: RtI Framework
[ ] Academic: Screening & Progress Monitoring
[ ] Academic: Reviewing K-5 Universal Reading Instruction
[ ] Academic: Reviewing K-12 Universal Mathematics Instruction
[ ] Academic: Reviewing Selected and Intensive Levels of Support
[ ] Academic: RtI Coordinators Roundtable/Networking
[ ] Behavior: Tier 1 Administrative Overview
[ ] Behavior: New Coaches Orientation: Nuts and Bolts
[ ] Behavior: Developing your Tier 1 Universal System
[ ] Behavior: Tier 2/3 Administrative Overview
[ ] Behavior: Building a Tier 2/Secondary System
[ ] Behavior: Tier 3: Complex FBA, Wraparound, or RENEW
[ ] Behavior: Coaches Networking
[ ] Behavior: New Team Member Training
[ ] Behavior: Wisconsin PBIS Conference (August 2014)
[ ] Integrated: Integrated Networking Technical Assistance
[ ] Integrated: Leadership and Coaching for RtI
[ ] Integrated: Cultural Responsive Classroom Practices
[ ] Integrated: Universal Design for Learning
Section 5: Implementation Self Assessments
**Self-assessment scores at fidelity (from May 1, 2014 through current) are required to receive recognition at
the merit level. At least two consecutive years (May 1, 2013 through May 1, 2015) at fidelity are required to
receive recognition at the distinction level.
Behavior: Benchmarks of Quality (BoQ) scores will be reviewed through PBIS Assessment website. Be
sure that your scores are submitted through PBIS Assessment website prior to submitting your application.
5.) Please read and check the box below*
[ ] *I have verified that our Benchmarks of Quality (BoQ) is updated and accurate on PBIS Assessment website and
we have scored at fidelity (70%) (May 1, 2014 through current)
Section 6: Student Level Data
In order to implement a culturally responsive multi-level systems of support it is important to begin looking at
both academic (reading and mathematics) and behavior student level data and disaggregate it by student
subgroups. We ask that you share your behavior student level data with us and in one academic area, either
Reading OR Mathematics to begin making connections with your data.
6.) Which academic area are you willing to share your data with us?
( ) Mathematics
( ) Reading
( ) Data not available or not willing to share our academic data at this time
6.1) Office Discipline Referrals by year
Please provide us with as much of your office discipline data by year starting with 2009 to 2014 as you can. If
possible disaggregate by % with and without disabilities and race. Please indicate NA in the boxes that you
need to leave blank. ***At least 2013-14 AND Year to Date 2014-15 years of data is required to qualify for
recognition and at least 2013-14 AND Year to Date 2014-15 years of data by race and disability is required to
qualify for distinction***
Year to
Date
2014-2015
Total # of students enrolled*
Total # of ODRs*
Total # of students with ODRs*
# of students with 0-1 referrals*
# of students with 2-5 referrals*
# of students with 6+ referrals*
% of students without disabilities with 1
or more ODRs
% of students with disabilities with 1 or
more ODRs
% of American Indian/Alaskan Native
with 1 or more ODRs
% of Asian with 1 or more ODRs
% of Black with 1 or more ODRs
% of Hispanic/Latino with 1 or more
ODRs
% of White with 1 or more ODRs
% of Native Hawaiian/Other Pacific
Islanders with 1 or more ODRs
% of Multi-racial with 1 or more ODRs
20132014
20122013
20112012
20102011
20092010
Reading OR Mathematics Screening Data
Please provide us with as much of your reading screening data for one grade and years from 2012 to 2014
as you can. If possible disaggregate by % with and without disabilities and race.
6.3) Select which grade level(s) you would like to submit for your reading or math screening data?
Yes
No
Grade 1
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Grade 2
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Grade 3
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Grade 4
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Grade 5
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Grade 6
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Grade 7
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Grade 8
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Grade 9
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Grade 10
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Grade 11
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Grade 12
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What is the name of the screening tool/measurement used for the data to be reported in this
table?*_________________________________________________
(Reading or Mathematics) Note: We are looking for screening data over the past 3 years. Use the screening tool
that provides the most data over this period.
If you have more than one grade you would like to submit data for, please make a copy of the table below to enter
your data. When entering grade level data into SurveyGizmo a table will appear for each grade selected in the
question above.
Fall
2014
Total number of students enrolled
Total number of students
screened
% of all students screened and
meeting benchmark proficiency
% of Students without disabilities
meeting benchmark proficiency
% of Students with disabilities
meeting benchmark proficiency
% of American Indian/Alaskan
Native students meeting
benchmark proficiency
% of Asian students meeting
benchmark proficiency
% of Black students meeting
benchmark proficiency
% of Hispanic/Latino students
meeting benchmark proficiency
% of White students meeting
benchmark proficiency
% of Native Hawaiian/Other
Pacific Islander students meeting
benchmark proficiency
% of Multi-racial students
meeting benchmark proficiency
Spring
2014
Fall
2013
Spring
2013
Fall
2012
Spring
2012
Fall
2011
Section 7: Narratives
7.) Explain how your implementation team creates action plans using your system level implementation results
(BoQ/SAS) in collaboration with your student level data.* (500 word limit)
7.1) Describe how you systemically ensure culturally responsive practices at the universal level for all students including
students with disabilities and students of different cultural backgrounds. Consider the following examples:
instructional practices, staff professional development opportunities, imaging and affirmations, policies, etc.* (500
word limit)
7.2) Provide specific examples of how you have actively engaged families in your school-wide implementation through
use of collaborative decision making and communication. * (500 word limit)
7.3) Using data from the past 2 years highlight any student outcomes seen (school climate, attendance, suspensions,
academic, etc.) due to your implementation. - include baseline and current (growth) data to support your example. *
(500 word limit)
7.4) Describe how your school teaches and re-teaches school-wide expectations throughout the current school year to all
students and all staff (including new staff).* (500 word limit)
7.5) Describe how you have implemented PBIS in ALL of your classrooms. Provide descriptive examples of how
classroom expectations and procedure were defined and taught, and classroom acknowledgement and consequence
systems. * (500 word limit)
Section 8: Recognition Information
8.) Enter the school name that you would like on your recognition banner. (25 characters maximum) (PLEASE BE
SURE YOU HAVE THE CORRECT SPELLING, IT WILL APPEAR EXACTLY AS ENTERED.)**
_________________________________________________
8.1) What is the school motto you would like on your banner? (60 characters maximum) (PLEASE BE SURE YOU
HAVE THE CORRECT SPELLING, IT WILL APPEAR EXACTLY AS ENTERED.)**
_________________________________________________
8.2) Banners will be distributed to all recognized schools at the 2015 PBIS Summer Leadership Conference. If your
district or school does not have someone attend the conference, we will mail the banner to your school.
Please provide the name and address of the person you would like your recognition banner mailed to.*
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