Student Success Team (Sst) Log Form 1

STUDENT SUCCESS TEAM (SST) LOG FORM 1

Log Dates from / to
Contact Person Responsible for Maintaining Log
School / School Number
Student Name / Referral Source / Birth
Date / Ethnicity / Date SST Referral / Type of Referral / Date SST Mtg. #1 / Outcome See Legend / Date SST Mtg. #2 /

Outcome

/ Comments
1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
10. 
11. 
12. 

A. Stop – resolved

B. Transferred or withdrawn Type of Referral: Attendance, Behavior

C. Develop/use a support system in the school Academic, Other, etc.

D. Develop/use a support system with community assistance

E. District Resources/Alternatives outside the school site

F. Referred for Special Program assessment, determination of eligibility; specify program

G. Other, specify in Comments box

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