Define The Problem/Develop Assessment Plan

PSM-3 Page 1 of 2

NC Department of Public Instruction

Problem-Solving Model Level III Performance Summary/Assessment Plan Development

Student Name: ______Date______

Area(s) Targeted for Instruction/Intervention: ______

Domain / General Concerns
(Relevant Known information) / Hypotheses of Reason for Area of Concern (Why is the student performing at a level of concern?) / Questions to Support or Refute Hypotheses / Assessment Plan for Target Area(s) (validate hypothesis or determine most probable cause) Consider RIOT / Person Responsible for Assessment Plan
Environmental Factors
Environmental changes
outside of school
Medical Factors
Counseling
Transience
Attendance/Tardiness
Curriculum
Curriculum content
Instructional materials used
Progress Monitoring/ Assessment

Examples of questions that might be asked: Where does the behavior occur? With whom does the behavior occur? When does it occur? How often does itor occur? How long does the behavior occur? Why is the student performing at a level of concern? What factors are contributing to the mismatch that exists between actual and desired levels of performance? Is the problem due to a skill deficit, performance deficit, or both?

NC Department of Public Instruction

Problem-Solving Model Level III Performance Summary/Assessment Plan Development

Student Name: ______Date______

Area(s) Targeted for Instruction/Intervention: ______

Domain / General Concerns
(Relevant Known information) / Hypotheses of Reason for Concern (Why is the student performing at a level of concern?) / Questions to Support or Refute Hypotheses / Assessment Plan for Target Behavior (validate hypothesis or determine most probable cause) Consider RIOT / Person Responsible for Assessment Plan
Instruction
Level of instruction
Rate of instruction
Presentation of instruction
Teacher/student ratio
Instructional transitions
Learner
Social/behavioral skills
Understanding of instruction
Internally/externally
motivated
Ability to engage in and remain on task
Organizational skills

Examples of questions that might be asked: Where does the behavior occur? With whom does the behavior occur? When does the behavior occur? How often does the behavior occur? How long does the behavior occur? Why is this problem situation occurring? What factors are contributing to the mismatch that exists between actual and desired levels of performance? Is the problem due to a skill deficit, performance deficit, or both?

Date & Time for Review Meeting:______

Revised 10/06