09/2014
Hart County Schools – Teacher Assistance Team (TAT)
--TAT Meeting Record--
STUDENT NAME & GRADE: ______MEETING DATE: ______# ______
STUDENT DOB & AGE: ______
REFERRING PERSON: TEACHER PARENT OTHER: ______
□ INITIAL TAT REFERRAL □ TAT REVIEW (complete all Sections I-IV)
NOTE: Teacher must bring the “TAT Checklist” & “Documentation of Interventions” along with needed info on the checklist to the TAT. A “Teacher Input Form” should be completed by EVERY teacher that the child has on a daily basis. All must be attached to this completed form.
I. Reason(s) for referral to TAT [check and circle ALL areas that are a concern]:
□ Cognitive [please explain]: ______
□ Academic: Reading Math Written Expression [explain concerns for each circle area]: ______
______
______
______
□ Communication: Receptive Language, Expressive Language, Articulation [specify concern(s)]:______
□ Social-Emotional: Social Skills Behavior Emotional Issues Adaptive Skills [explain]: ______
______
______
□ Medical [list diagnosis/diagnoses)]: ______
*Does the school have a copy of a medical statement verifying above diagnosis/diagnoses? YES NO
IF “YES” attach to TAT paperwork
IF “NO” please explain (when, how, who providing statement): ______
*IF school is to obtain the medical statement, a “Release of Information – HIPAA” must be completed and attached at TAT
*IF parent obtaining medical statement, parent must be provided a “Hart County Schools Medical Statement” to be returned to
school personnel as quickly as possible
□ Motor: Gross Motor Fine Motor [please explain]: ______
□ Other [please explain]: ______
□ Review only – no changes for Section I
II. Interventions & Progress Monitoring:
· “Documentation of Interventions” form must be completed AND attached to this form
· Progress monitoring data must also be attached for EACH intervention implemented
III. Recommendations of TAT:
□ Continue with interventions: ______
□ Dismiss from TAT: ______
□ Refer for an evaluation with a suspected disability of: ______
IF moving to referral, TAT packet will be given to special education teacher/case manager so the following can be completed in the listed order PRIOR to scheduling the referral ARC:
· Does student need a speech screener? If so – please contact your SLP
· A vision and hearing screener MUST be completed prior to referral – IF child fails either, STOP and contact school psychologist
· Referring teacher and special education teacher/case manager complete “Referral” packet together from Infinite Campues pgs 1-5
(PLEASE DO NOT SKIP ANY AREAS ON THE REFERRAL PACKET – AS IT WILL ONLY DELAY THE REFERRAL PROCESS)
· Coordinate dates with all ARC members for the meeting prior to scheduling
· Send out Notices of ARC and prepare for ARC by starting draft of “Conference Summary Referral – Initial”
IV. Signatures of TAT Team Members in Attendance:
______
______
______
______
*NOTES section on back of page
NOTES: