Building Intervention Team

School: Student Name:

Date:Date of Birth: Age: Grade:

Referring Teacher:
  1. Behavior or concern:

Review of Student History:

  1. Are the parents aware of concern? Parent Contact? Date Time
  1. Has the student previously been referred or screened for special education?

If so, when?

  1. Has the student repeated a grade? If so, when?
  1. Attach a copy of last vision and hearing screening
  2. Vision Screening Choose an item.
  3. Hearing Screening Choose an item.
  1. Is there anything happening in the family which would be contributing to the child’s difficulties? (Information based on facts)
  1. Does the child have any physical, vision, or hearing problems, or illnesses that would affect academic performance?
  1. Does the child take any medication?

If yes; purpose:

  1. Record review:
  1. Transcript and last grade report (attach copy)
  2. Attendance record (attach copy)
  3. Criterion reference scores (attach copy)
  4. Standardized testing results (attach copy)

WY-TOPP:Math:Choose an item.Reading: Choose an item.

DIBELS: Expected Choose an item.

DIBELS: Expected Choose an item.

AIMS Web: Expected Score Choose an item.

Other: Math:Choose an item.Reading: Choose an item.

Other: Math:Choose an item.Reading: Choose an item.

  1. Previous teacher concerns
  1. Previous intervention(s) tried:

Dates of: from to

Intervention:

Results:

  1. Interventions suggested by B.I.T.:

Read NaturallyChoose an item. Phonics BoostChoose an item.

Sue BartonChoose an item. Lights OnChoose an item.

Math EssentialsChoose an item. CounselingChoose an item.

TutoringChoose an item. BLITZChoose an item.

ReadstersChoose an item. Lang. for LearningChoose an item.

Other:

Comments:

Next steps:

a. Stop referral

b. Refer to these community resources

c. Refer to other School Program:

d. Refer to school team for possible 504

e. Refer to Special Education (not applicable to articulation)

The team agrees that circumstantial disadvantage does not substantially contribute to the

student’s learning problems.

The team substantiates that the learning or behavior problem is adversely affecting

educational performance.

f. Immediate referral to Special Education for articulation.

g. Continue BIT.

h. Next Meeting Date:

Team Members signatures:

Member: ______Date: ______

Member: ______Date: ______

Member: ______Date: ______

Member: ______Date: ______

Chairperson: ______Date: ______

Principal: ______Date: ______

Minutes of Building Intervention Team Meeting

Student Name: School:

Fremont County School District 6Pavillion, WY 82523