FORMS USED IN THE STUDENT INTERVENTION TEAM PROCESS
FORMS USED IN THESTUDENT INTERVENTIONTEAM PROCESSProper documentation is essential in the Student Intervention Team (SIT) process. Forms should provideadequate documentation of the team’s activities. Written summaries of the team’s actions should be kept forevery meeting. The actions of the SIT should be so clear that new teachers/staff each year will have nodifficulty determining what has been tried and found successful for the student in the past.
St. Louis Public SchoolsSTUDENT INTERVENTION TEAM PROCESS CHECKLISTThe purpose of this checklist is to serve as a guide for effectively implementing the SIT process.It is to be maintained by the School Guidance Counselor.NameID DOBReferred byDateDateActivityTeacher notifies parent, student, principal, and SIT Coordinator that there is a need to open a SIT case for anunresolved academic and/or behavioral problemSIT Coordinator provides teacher with the following SIT referral forms:Request for Student Intervention Team Assistance Section ARequest for Student Intervention Team Assistance Section B– Teacher Input Form for AddressingProblem BehaviorsClassroom Teacher completes the request forms and return them to the SIT CoordinatorStudent data and supporting evidence gatheredSIT Coordinator schedules the first SIT meeting and invites parent and additional SIT members based on theneeds of the studentSIT Coordinator sends parent invitation/notification of meeting along with the Student Intervention Team–Parent Input FormParent to attend?YesNoAccommodations needed and arranged? (e.g., language interpreter, sign language interpreter )YesNoSchool Guidance Counselor assists or arranges assistance to student in completion of the StudentIntervention Team– Student Input FormConvene initial SIT meetingDate TimeSend reminder notices to SIT members, including parentCopy of strategies provided to all implementersComplete SIT Plan.SIT Meeting Summary completedImplementation of intervention strategies being monitoredConvene SIT meeting #DateTimeSend reminder notices to SIT members, including parentSIT reviews documentation and evaluates success of intervention strategiesSIT decides on plan of actionDevelop new modificationsContinue current modification, if successfulCease modificationsSIT Meeting Summary completed.Convene SIT meeting #DateTimeConvene SIT meeting #DateTimeConvene SIT meeting #DateTimeConvene SIT meeting #DateTimeInterventions successful. Student returned to general education without supports. SIT file closed.Interventions successful. Student returned to general education without Tier I or II supports. SIT filereturned to Collaborative Support Team FacilitatorInterventions unsuccessful. Student referred to Referral Review Team
St. Louis Public SchoolsSTUDENT DATA PROFILEName ID DOBAgeSchool Room/Grade TeacherParent(s) TelephoneAddress Zip CodeAAt-Risk Student Referral FormDate of RequestPerson making the request Role*For parental requests for SIT assistance, parent should complete the Student Intervention Team-Parent Input Form, pages1 & 2.*For student requests for SIT assistance, student should complete the Student Intervention Team-Student Input Form,pages 1 & 2.Reason for Request - What are the concerns about the student’s performance?* If the student exhibits social/behavioral concerns, also complete Student Data Profile-Section B.How and when was parent first notified of the student’s concerns?Phone call (date)Letter (date)Conference (date)Note concerns expressed by the parent.SDP - Section A, p. 1 (09-2010)
NameI.ID DOB SchoolACADEMIC SKILLS - Identify any areas in which the student displays a significant strength (S) or concern(C). Gather work samples to illustrate the student’s concerns.READINGsight word recognitionphonics skillscomprehensionOtherEstimated Grade LevelMATHcomputationreasoningOtherEstimated Grade LevelWRITTEN LANGUAGEsentence structurevocabularyorganizationspelling and/or punctuationOtherEstimated Grade LevelORAL LANGUAGEoral expressioncommunicating with peerscommunicating with adultsfollowing verbal directionsOtherSPELLINGEstimated Grade LevelII.III.STUDENT STRENGTHS – Check all that apply.Positive AttitudeHandles conflict wellWorks well independentlyTrustworthyTakes pride in appearanceCooperatesRespectful of AuthorityArtistically inclinedTransitions easilyOrganizedHigh expectations for selfHard WorkerAthleticGood sense of humorWorks well in groupsMusically talentedResponsibleMotivatedPossesses leadership qualitiesOtherIdentify areas in which the student displays significant difficulties or functions significantly below theexpected level.LEARNING BEHAVIORSworking in a groupworking independentlydistractibilityimpulsivityenergy level too highenergy level too lowfrustration toleranceorganizationSDP - Section A, p. 2 (09-2010)SOCIAL ADJUSTMENTdevelops appropriate friendshipsrelates appropriately to teachers – adultsemotional outburstswithdrawalchronic lyingchronic cheatingchronic absencesstealingbullyingdifficulties at home
NameID DOB SchoolPROCESSING (motor/auditory/visual)fine motor skills/eye-hand coordinationgross motor skills/general clumsinessreversal/transportations (letters, words, numbers)manuscriptcursive writingcopying from boardvisual memoryright/left confusionauditory memoryOtherADAPTIVE SKILLS (compared with same age peers)delayed self-help skillssocially immatureimmature languageOtherCOGNITIVEBelow average compared to peersAverage compared to peersAbove average compared to peersIV. EDUCATIONAL HISTORYNumber of Schools Attended:Grades Repeated: (Specify)Excessive Absenteeism:GradeDays AbsentDays AbsentGradeGradeDays AbsentExtenuating Reason(s) for excessive absenteeism [date(s) and specify (severe illness; hospitalization, etc.)]:Number of Suspensions:Is the student involved in English for Speakers of Other Languages (ESOL)?NOYESHas instruction been inconsistent within a school year?NOYES, specify (e.g., series of substitute teachers) and give datesHas the student had a change in the classroom assignment or a change in teachers this school year, last school year,etc.? NOYES, describeAre academic deficiencies a result of lack of instruction in reading and/or mathematics?NOYES, explainAdditional relevant factors:SDP - Section A, p. 3 (09-2010)
NameV.ID DOB SchoolFor Grades K-5, check hereand see Intervention Plan Components/Monitoring in the IndividualAcademic Plan (IAP). For Grades P, 6-12, complete the following section.What classroom intervention strategies have been employed to address the student’s academic concernsprior to the SIT request? Check all that apply.InterventionHow Long Tried?Outcome of InterventionEnter begin and end dates.Instructional accommodationsSpecify:Modified curriculum/demandsMaterials modification –Alternative materialsSmall-group instructionTutoringAssistive technologyDaily guided readingESOL SupportContractAssigned seatingRearranged physical settingProblem-solving conferencewith Collaborative Support TeamParent ConferenceOther – Specify:Other –Specify:Other –Specify:Specific Tier 1 SupportSpecific Tier 2 SupportSpecific Tier 3 SupportVI. Student Data and EvidenceDocumentation must be provided for each student concern. Following are examples of the types ofevidence that may be used to support the SIT process. Gather your supporting evidence and check eachtype of evidence you will be bringing to the first meeting of the Student Intervention Team.Individual Academic Plan (IAP)ObservationsAttendance RecordsClass quizzes and testsReport CardDiscipline FormsStudent Work SamplesOther pertinent SIS informationRecord of out-of-school (OSS) and in-school (ISS) suspensionsAppropriate anecdotal records, outside reports (behavioral, medical, psychiatric)Any other pertinent information, specifySDP - Section A, p. 4 (09-2010)
NameBID DOB SchoolSt. Louis Public SchoolsTEACHER INPUT FORM FOR ADDRESSING PROBLEM BEHAVIORS(Section B should be used only if behavior is an area of concern)1. Describe the behavior(s) of concern. Use measurable terms.Example: Rather than “Lisa picks fights”, describe the actions and frequency. “Lisa demonstrates aggressivebehavior toward other students at least 2-3 times a day, often more. She shows her aggression by such actions aspushing, grabbing materials from others, and by using verbal commands and name-calling.”2. Where does the problem occur? Check all that apply.ClassroomSchool groundsCafeteriaGymHallwayBusHomeOther3. When is the behavior most likely to occur?a. On a particular day: MondayTuesdayWednesdayThursdayFridayb. At a particular time(s) of the day, such as morning, afternoon? If so, when?c. During instructional activities, such as math or independent work? If so, when?d. When interacting with certain people – individuals or groups? If so, who?e. During non-instructional time such as changing classes, playground, lunch time? If so, when?f.When physically tired, hungry, or sick? If so, which?4. What do you think the student gains or avoids by demonstrating the behavior?Get attention? From whom?Avoid attention? From whom?Get control? Of what?Avoid embarrassment? From what?Avoid task? Which?Other?5. How have you conveyed your expectations to the student?SDP- Section B, p. 1 (09-2010)
NameID DOB SchoolSt. Louis Public SchoolsTEACHER INPUT FORM FOR ADDRESSING PROBLEM BEHAVIORS, p.27. Describe the specific expectations you have for the student that are not being met.8. Do you think the student cannot (is unable to) or will not (is unwilling to) demonstrate the appropriate/desired behavior? Why?9. What techniques have you already tried to help the student meet behavioral expectations?Technique/InterventionHow Long Tried?Enter begin and end dates.posted rules for the whole classdenied desired items/activitiesimmediate feedbackteacher-student contractpositive verbal reinforcementignored the behavioroffered options/choicesreward systemdetentionnotes/phone calls to parentsreferral to the school counselorrearranged physical settingproblem-solving conferencewith Collaborative Support Teamreferral to the officeOther – Specify:Other –Specify:Other –Specify:Specific Tier 1 SupportSpecific Tier 2 SupportSpecific Tier 3 SupportSDP - Section B, p. 2 (09-2010)times in weeksOutcome
St. Louis Public SchoolsSTUDENT INTERVENTION TEAM– STUDENT INPUT FORMThis form should be used when more in depth student input is desired. Interviewer should modify the language in thisinput form to consider the age of the student.Name ID DOBAgeSchool Room/Grade TeacherInterviewer’s Name/RoleDateI. About MeWhat are your greatest strengths? In what areas do you do best? What are you most proud of doing?I have a positive attitude.I am motivated to do a good job.I am a good leader.I am a hard worker.I deal with conflict well.People can trust me.I am organized.I have a good sense of humor.I am attractive.I work well in groups.I work well by myself.I cooperate with others.I am good at music.I am good at art.I am respectful.I am responsible.I finish my work.I am creative.OtherOtherAre you involved in any sports/clubs/activities at school or outside of school? If so, what?II. My ConcernsI have difficulty:Getting good gradesFinishing my workFollowing directionsRemembering thingsWriting assignmentsWorking by myselfReadingWorking with othersDoing mathStudying for testsOtherBehaviors I need help to stop doing:Does not apply.Physically hurting peopleDestroying propertyStealing/cheating/lyingSaying mean thingsBeing easily distractedGiving up easilyBullying othersAnnoying peopleSkipping schoolGetting mad easilyBeing shyBeing late to schoolOtherIf the concern is behavior, where do you need the help?ClassroomSchool groundsCafeteriaHomeOtherSIT Student Input, p.1 (09-2010)HallwayBus
St. Louis Public SchoolsSTUDENT INTERVENTION TEAM– STUDENT INPUT FORM, p. 2NameID DOB SchoolWhat class/subject is giving you the most difficulty? What makes it difficult?If we picked one thing to focus on, what would you like for us to work on that would help you improve at school?III. How to Help MeWhen you think about what area you need help improving, think about what helps you learn best: Are there certain materials/papers/assignments that make learning more or less difficult? What is your favoritekind of assignment? What is your least favorite kind of assignment? Are there things about the classroom or where you study at home that make learning more or lessdifficult?SIT Student Input, p. 2 (09-2010)
St. Louis Public SchoolsSTUDENT INTERVENTION TEAM– PARENT INPUT FORMThis form should be used when more in depth parental input is desired.Student Name ID Date of BirthSchool Room/Grade TeacherParent(s) TelephoneAddress Zip CodeAccommodations Required? YES,(e.g., interpreter, accessible access, etc.)NORelevant Health Information – Provide Health Data Forms to the School Nurse.Identify any physical/health concerns that you feel may be interfering with your child’s academic/school success.What would you like your child to be able to do? Describe.What has been tried to help your child? Describe.Where does the problem occur? Check all that apply.ClassroomSchool groundsCafeteriaHallwayHomeOtherSIT-Parent Input, p. 1(09-2010)Bus
St. Louis Public SchoolsSTUDENT INTERVENTION TEAM– PARENT INPUT FORMStudent Name ID Date of BirthChild’s Strengths - Check all that apply.Positive AttitudeHard WorkerTrustworthyWorks well in groupsWorks well by himself/herselfRespectfulPossesses leadership qualitiesFinishes what he/she startsHandles conflict wellOrganizedAthleticGood sense of humorTakes pride in appearanceCooperatesMusically talentedResponsibleArtistically inclinedCreativeMotivatedOtherConcerns About How My Child is Learning - Check all that apply.Poor gradesDoes not work well by himself/herselfPoor writing skillsDisorganizedDoes not work well with othersPoor reading skillsDoes not finish workGives up easilyPoor math skillsDoes not follow directionsDoes not remember thingsPoor study skillsOtherConcerns About How My Child Behaves - Check all that apply.Physically hurts peopleSays mean thingsIs sexually inappropriateIs bulliedShy/withdrawnGives up easilyBullies othersGets mad easilyIs late and/or skips schoolDestroys propertyAnnoys peopleIs easily distractedSteals/cheats/liesAvoided by peersArguesOtherAdditional information that you feel would help the school assist your childSIT Parent Input, p. 2 (09-2010)
St. Louis Public SchoolsSTUDENT INTERVENTION TEAM - PARENT NOTIFICATION OF MEETINGDateRe Date of Birth SchoolDear Parent(s):(Check if this is the initial SIT meeting.)We are requesting assistance from our Student Intervention Team on behalf of your child. This is a regulareducation process whose function is to provide insight and specific suggestions to help the classroom teacher and schoolstaff work with your child most effectively. We made this request because(Check if this is a subsequent SIT meeting.)As you know, your child is being served through the Student Intervention Team process. This team meetsperiodically to assess progress of the intervention plan and make new decisions based on plan outcomes.Enclosed you will find a School Intervention Team – Parent Input Form which is designed to give us moreinformation about your child. We are interested in any information which you feel could help us better understandyour child. Please complete the forms and return it to me as soon as possible. All information will be regarded asconfidential, and is accessible only to those who have a legitimate need to know it.A meeting has been set for (date) at (time).We will meet at School, in room .Through the collective efforts of the Student Intervention Team, which consists of teachers, administrators, and others wehope to develop successful methods of helping your child have a more productive school year. Parental input isconsidered very important and your attendance is appreciated and invited. We appreciate your support of our efforts. Ifyou have any questions, please contact me.Sincerely, (Name/Title) (phone number).(Complete and return the section to the school.)Student Date of Birth SchoolYes, I will attend the SIT meeting for my child on .No, I cannot attend the SIT meeting. Please contact me with the results.Parent/Guardian SignatureSIT Meeting Notice-Parent (09-2010)Date
NameID DOB SchoolSt. Louis Public SchoolsSTUDENT INTERVENTION TEAM PLANGeneral Education Intervention Implementation and Progress Monitoring(Use as many pages as necessary)Concern # Be specific and provide as much detail as possible.Desired OutcomeResponsible Person for this InterventionLength of InterventionFrom ToWhat, if any, special instructional or behavioral materials/resources or training is needed for this intervention?How will the success of the intervention be measured? Progress Monitoring PlanOn what date(s) will the Progress Monitor (if not the teacher) check in with the teacher about the intervention?Date Date Date DateObserved Improvement YesNoDescribe and attach graphs or other documentation.Outcome Option for this Intervention - Check one.1 - Strategies were successful. Exit SIT interventions. Student remains in general education without the need for furtherintervention or with Tier I or Tier II interventions.2 -Progress is noted. Continue present intervention/services with no changes until next meeting date3 - Interventions minimally/not successful. Continue SIT and develop a new plan at next meeting date4 - Interventions exhausted. Refer to Referral Review Team to determine eligibility for special education. Disability suspected.SIT-Plan (09-2010)
St. Louis Public SchoolsSTUDENT INTERVENTION TEAM MEETING SUMMARY-page 1(Use as many pages as necessary)NameID DOB SchoolDate of MeetingStart Time:End Time:Meeting Location;Meeting Status:This is on-going SIT meeting # .This is the final SIT meeting.Team Members PresentRole/Meeting Facilitator/Time-Keeper/Recorder/Progress Monitor/Support TeamDesignated ConsultantPurpose of the MeetingInformation ReviewedGoal Statement for the StudentSIT-Summary, p. 1 (09-2010)
St. Louis Public SchoolsSTUDENT INTERVENTION TEAM MEETING SUMMARY-page 2NameID DOB SchoolConcerns Identified/Discussion SummaryRecommendationsDesignated person to share meeting information with the parent, if not in attendance.A summary of the meeting should be sent to the parent.Outcome of MeetingSIT-Summary, p.2 (09-2010)
Phase IV - STOPIf the student has not achieved successthrough SIT interventions, exhaust allinterventions. Refer to Referral ReviewTeam to determine eligibility for specialeducation. Disability is suspected.
NameID DOB SchoolSt. Louis Public Sc
School Guidance Counselor assists or arranges assistance to student in completion of the Student Intervention Team– Student Input Form . Convene initial SIT meeting Date_ Time_ _Send reminder notices to SIT members, including parent _Copy of strategies provided to all implementers _Complete SIT Plan. _SIT Meeting Summary completed _Implementation of intervention strategies .
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