Missouri SW-PBS School Recognition Program
School Application
2014-2015
The purpose of the Missouri SW-PBS School Recognition Program is to identify and recognize
Missouri schools for successful implementation of School-wide Systems of Positive Behavior Support.
Criteria are based on effective implementation of the essential components outlined by the OSEP
Center on Positive Behavioral Interventions and Support. Successful applicants will demonstrate
superior performance in the following areas:
1.
2.
3.
4.
5.
Use of data to direct instruction, problem solving and intervention efforts
Active use of creative and engaging recognition systems
Implementation of SW-PBS throughout the school environment
Systemic orientation of new students, parents and staff throughout the year
Active instruction for social and behavioral skills
Instructions:
 Application will be electronic, see pbismissouri.org for details to access to a fillable PDF.
Submit the application to moswpbs@missouri.org
 All additional materials must be completed and submitted by mail or electronically to your
regional SW-PBS consultant no later than April 15, 2015.
 Materials regularly submitted to consultant do not need to be copied, inserted, or submitted as
artifacts.
 Notification of the award will be made by May 10, 2015.
RECOGNITION RECIPIENTS MUST AGREE TO SERVE AS DEMONSTRATION SITES FOR SW-PBS.
Demonstration sites may be called on to share their success in the following ways: (1) allow representatives
from schools or districts to visit your building and attend a SW-PBS Leadership Team meeting, (2) share
materials related to implementation, (3) provide data and other aspects of the implementation process for
publication purposes, (4) participate in videos or other electronic tutorials produced by MO SW-PBS, and (5)
arrange for SW-PBS information from your district/school to be displayed on your website.
To be considered for the Missouri SW-PBS School Recognition Program, this application and supporting
documents must be submitted in accordance with the established timelines and meet all criteria.
For Official Use Only
Date Received: __________________________
Application Complete: Yes_______ No________
Received By: ___________________________
Identifying Information
School and District Name:
SW-PBS Consultant:
School Website:
Circle all tiers at which your school has received instruction/support from SW-PBS consultants during
the 2014-2015 school year:
Tier 1
Tier 2
Tier 3
Other pertinent information if applicable:
_______________________________________
Person Completing School Application Signature
_______________________
Date
_______________________________________
School Principal Signature
_______________________
Date
SW-PBS Contact Person for Your School: _____________________________________
SW-PBS Contact Person’s Email: ____________________________________________
SW-PBS Contact Person’s Phone: ____________________________________________
*Note: Materials regularly submitted to consultant throughout the year do not need to be copied and
inserted into recognition artifacts. These items will be denoted within the scoring rubric.
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Narrative
Please submit a narrative describing your SW-PBS Tier 1 process as it relates to each item listed across
categories of systems, data, and practices. Respond to each of the categories in the order they are listed
below (systems, data, and practices). To provide a guideline, schools that have previously submitted
successful recognition applications have been able to complete the narrative section using 1,000 words
or less.
1. Systems:
A. Briefly describe your system (on-going plan) for communicating your SW-PBS
process with all faculty/staff/students/families throughout the school year.
2. Data:
A. Briefly describe how Big 5 data is reviewed and used (1) to identify social
behavioral skills for re-teaching/reminding and/or intensifying practice and (2)
to inform staff on a regular basis.
B. Explain how your school uses the instruments listed below to inform decisionmaking:
 Self-Assessment Survey (SAS)
 School Safety Survey (SSS)
 Schoolwide Evaluation Tool (SET) or Benchmarks of Quality (BoQ)
C. Select two or more of the following and briefly describe evidence of improved
outcomes or sustained outcomes over a period of years. Check those addressed:
 ____ Big 5 data reports
 ____ Overall student attendance
 ____ Overall tardy rates
 ____ Overall student rates of ISS, OSS or Expulsion
 ____ ODR data within the national range for your school’s grade levels
 ____ Staff retention rates
 ____ School Data Profile
3. Practices:
A. Explain how teaching and encouraging social/behavioral skills consistently
and with fidelity, improved the culture and climate in your building.
4. Unique Features:
A. Include any other pertinent information you would like to share concerning
unique features of the SW-PBS work in your school.
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Missouri SWPBS Recognition Program – Scoring Checklist 2014-2015
Revised 110314
*Artifacts and data submitted to regional consultants throughout the year do NOT need to be re-submitted. These items are denoted by *
BRONZE SYSTEMS
Requirement
What to Submit
1.
A Team is in place and meets regularly

Team meeting minutes submitted on time (*)
2.
Consistent team membership and attendance
by administration

Team meeting minutes including participant attendance (*)
3.
Implementation sustained by communication
and professional development for all staff (i.e.
ongoing feedback and support)

Team Meeting minutes (*)
or
Staff meeting minutes
or
Universal Checklist (*)
or
Current Action Plan (*)
Sections of Student/Family Handbook that address Expectations and
behaviors/rules
or
Newsletters
or
School district website




4.
Expectations and behaviors/rules
communicated to students, families, and
community


5.
A continuum for encouraging expected
behaviors is documented



6.
A continuum for discouraging inappropriate
behaviors is documented


Bronze
Submit a copy of your school Recognition Matrix
and
Sections of Faculty/Student/Family Handbook that includes description of the
encouragement system
Flowchart or Chart with delineated levels of inappropriate behavior
and
Majors (office managed) and minors (staff managed) delineated and clearly
defined
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BRONZE DATA
Requirement
What to Submit
1. All required data submitted on time






Self-Assessment Survey (*)
School Safety Survey (*)
Team Meeting Minutes (*)
Universal Checklist (*)
Current Action Plan (*)
Big 5 Data Reports (*)
2. Evidence that review of Big 5 data is used to
identify social behavioral skills for reteaching/reminding and/or intensifying practice and
to inform staff on a regular basis

Description included in narrative
3. Explain how your school uses the designated
instruments to inform decision-making

Description included in narrative
4. Describe evidence of improved outcomes or
sustained outcomes over a period of years

Description included in narrative

Bronze
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BRONZE PRACTICES
Requirement
1.
2.
Evidence of regularly teaching
social/behavioral skills in all school-wide
settings and classrooms
Evidence classroom expectations, rules
and routines align with school-wide
expectations
What to Submit

Provide a copy of Documented Teaching Schedule.

Submit school-wide matrix with classroom column or individual teacher
classroom matrix example.

Bronze
and
3.


Required PBIS Surveys completed and
meet fidelity percentages
SET 80/80% or BoQ 80%
SAS completed by 80% of staff, with
minimum of 60% on Schoolwide,
NonClassroom and Classroom, with
70% preferred.

Submit a completed walk through observation form that includes classroom
expectations, rules and routines.



SET submitted by consultant
BoQ submitted by team on PBIS Assessment before April 1, 2015
SAS completed by 80% of staff members before April 1, 2015
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SILVER SYSTEMS
Requirement
What to Submit
1.
Specific Bronze Level requirements
continue to be evidenced

All Bronze Level Requirements met (as listed above)
2.
A team is in place and meets at least twice
a month

Complete and submit Benchmarks for Advanced Tiers (BAT)
3.
Consistent team membership and
attendance by a school administrator

Tier 2 Action Plan
4.
Tier 2 process communicated to all staff,
students, and families

Complete and submit Benchmarks for Advanced Tiers (BAT)
5.
A process is in place to identify function of
behavior

Submit Tier 2 Action Plan with goal and/or activities to fulfill the requirement.
6.
Evidence of an Action Plan with Tier 2
goals

Tier 2 Action Plan

Silver
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SILVER DATA
Requirement
What to Submit
1.
Evidence a method is in place to identify
students who require additional social
behavioral and/or academic support

Complete and submit Benchmarks for Advanced Tiers (BAT)
2.
Evidence Tier 2 team has a mechanism for
monitoring student data

Complete and submit Benchmarks for Advanced Tiers (BAT)
3.
Evidence the Tier 2 team uses data-based
decision making to fade, continue, modify
or intensify supports for identified
participants

Complete and submit Benchmarks for Advanced Tiers (BAT)
4.
Evidence team shares data and decisions
regarding interventions and student
outcomes with appropriate staff at least
quarterly

Complete and submit Benchmarks for Advanced Tiers (BAT)
5.
Team completes Benchmarks for
Advanced Tiers (BAT) annually and uses
results to develop action plan goals and
items

Complete and submit Benchmarks for Advanced Tiers (BAT)

Tier 2 Action Plan

Silver
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SILVER PRACTICES
Requirement

What to Submit
1.
Evidence minimum of 2 research-based
small group interventions are in place

Completed Intervention Essential Features for 2 interventions that are
successfully implemented in your setting (guide is provided in Tier 2 workbook
chapters)
2.
Documentation of student outcomes

Documentation of student outcomes using the following categories and format:
Name of Intervention
3.
4.
SET 90/90% or BoQ 80%
SAS completed by 80% of staff, with
minimum of 70% on Schoolwide,
NonClassroom and Classroom



Number of
Students who
Participated
Number of
Students that
Graduated
Silver
Number of students who participated in
Tier 2 intervention(s) but required more
intensive support.
SET submitted by consultant
BoQ submitted by team on PBIS Assessment before April 1, 2015
SAS completed by 80% of staff members before April 1, 2015
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GOLD SYSTEMS
Requirement

What to Submit
1.
Specific Bronze Level requirements
continue to be evidenced

All Bronze Level Requirements met (as listed above)
2.
Silver level requirements continue to be
evidenced

Silver level requirements are met.
3.
A team with designated roles and
responsibilities is in place to support Tier 3
process

Complete and submit Benchmarks for Advanced Tiers (BAT)
4.
Team membership includes access to an
individual with behavioral expertise and a
member of the school administrative team

Complete and submit Benchmarks for Advanced Tiers (BAT)
5.
System for full Functional Behavioral
Assessment (FBA) and Behavioral
Intervention Plan (BIP) process is in place

Complete and submit Benchmarks for Advanced Tiers (BAT)
6.
Tier 3 processes are communicated to all
staff, students, and families

Complete and submit Benchmarks for Advanced Tiers (BAT)
7.
Evidence of a Tier 3 Action Plan

Tier 3 Action Plan
Gold
GOLD DATA
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Requirement
What to Submit
1.
Evidence of data decision rules to identify
participants for Tier 3 supports

Complete and submit Benchmarks for Advanced Tiers (BAT)
2.
Data to support Tier 3 level planning and
interventions

Complete and submit Benchmarks for Advanced Tiers (BAT)
3.
BAT assessment results

Complete and submit Benchmarks for Advanced Tiers (BAT)

Gold

Gold
GOLD PRACTICES
Requirement
1.
One example FBA/BIP completed
according to guidelines outlined in the
FBA/BIP Evaluation Rubric.
What to Submit

One completed FBA/BIP that is accompanied by a Tier 3 Team self-assessment
using the FBA/BIP Evaluation Rubric.



SET submitted by consultant
BoQ submitted by team on PBIS Assessment before April 1, 2015
SAS completed by 80% of staff members before April 1, 2015
In addition to the completed team self-assessment a
regional Tier 2/3 Consultant also will evaluate the
submitted FBA/BIP using the evaluation tool. A
minimum score of 1 on each item and an overall
score of 80% are required.
2.
3.
SET 95/95% or BoQ 80%
SAS completed by 80% of staff, with
minimum of 70% on Schoolwide,
NonClassroom and Classroom
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