Enhanced Staffing Worksheet

ENHANCED STAFFING WORKSHEET

DATE:
1. / STUDENT INFORMATION / UIC #
Name: / DOB: / Sex: / Current Grade:
Address: / City/State/Zip:
Phone: / Ethnic Group: / Language:
Building: / Resident District: / Operating District:
Parent/Guardian/Surrogate: /

Language:

Special Education Teacher: / Classroom Staff:
Classroom Staff: / Classroom Staff:
2. /

ADDITIONAL STAFF RATIONALE The request for classroom enhanced staffing is being made due to one of the following conditions:

One student / Multiple students
3. /

SURVIVAL SKILLS SCALE Please check the box that most accurately describes this student’s survival needs

5 / Student has no significant survival skills-not safe without continuous hands-on adult supervision.
4 / Needs hands-on supervision during outings, transitions, open spaces & around appliances, utensils.
3 / Needs visual, direct–line supervision with appliances, utensils, contact with substances/persons & community setting
2 / Needs special supervision for special outings, needs direct-line, visual contact.
1 / Needs no additional supervision beyond what is provided to other students in the classroom.
The student has few or no survival skills & engages in behavior that puts him/her at risk for injury (e.g. running away, getting into restricted items). / Yes No
Describe the student’s survival skills & limitations (required):
______
______
List environmental modifications & interventions previously implemented (required):
______
4. /

AGGRESSION/DESTRUCTION SCALE Please check the box that most accurately describes this student’s aggressive/destructive behavior.

5 / ·Student has documented incidences of repeated aggression causing tissue damage to self or others and/or promoting health
risks to others by spreading bodily fluids, one time per month or more.
and/or
·Student has documented incidents of destructive behavior, and/or damage to property or school articles of value.
and/or
·Student is engaging in non-injurious aggressive behavior or inappropriate physical contact toward self or others (i.e., which
might be considered criminal behavior in community settings) multiple times daily
4 / ·Student has documented incidences of aggression resulting in injury or health risks to others 6 or more times per year, which
have significant impact on school/home environment.
and/or
·Student has frequent destruction of property that doesn’t have significant value, but is disruptive to the classroom multiple times
weekly
and/or
·Student engages in non-injurious aggressive behavior or inappropriate physical contact toward self or others, multiple times
weekly.
3 / ·Student has documented incidents of aggression resulting in people being hurt or upset, but not physically injured.
·Student has frequent destruction of property that doesn’t have significant value, but is disruptive to the classroom multiple times
monthly.
·Student engages in non-injurious aggressive behavior or inappropriate physical contact toward self or others multiple times
weekly.
2 / ·Student who becomes aggressive in situational or cyclical times or during specific activities.
·Student engages in destructive behavior which only interferes with his learning.
·Student engages in non-injurious aggressive behavior or inappropriate physical contact toward self or others multiple times
monthly.
1 / ·Student doesn’t display aggressive or destructive behavior
The student engages in aggressive/destructive behavior toward self & others. Documentation of staff/student injuries need to be addressed. / Yes No
Describe the student’s aggressive/destructive behavior (i.e., what it looks like, frequency, duration, intensity):
______
______
List environmental modifications & interventions previously implemented (required):
______
5. /

DISRUPTIVE BEHAVIOR SCALE Please check the box that most accurately describes this student’s aggressive/destructive behavior.

5 / ·Student disrupts almost every classroom activity on a daily basis.
4 / ·Student disrupts certain activities on a daily basis.
3 / ·Student is occasionally disruptive or disruptive with certain staff.
2 / ·Student is rarely disruptive, but has been on some occasions.
1 / ·The student doesn’t demonstrate a problem with disruptive behavior.
The student engages in severe and/or disruptive behavior that: 1) significantly impacts the teacher’s ability to carry out instruction in the classroom; or 2) significantly impacts other students to the point where they are too distracted to attend, or they become upset & angry. The student(s) cannot be safely or effectively managed with reasonable environmental modifications given the present staff-to-student ratio in the classroom. / Yes No
Describe the student’s disruptive behavior (i.e., what it looks like, frequency, duration, intensity):
______
______
List environmental modifications & interventions previously implemented (required):
______
6. /

BEHAVIOR PLAN SCALE Please check the box that most accurately describes the complexity & time requirements for efficient implementation of the student’s behavioral plan.

5 / ·The student’s plan involves dealing with frequent, daily interventions, time consuming ecological strategies, and/or reactive
strategies involving exclusionary time-out or physical/mechanical restraint occurring on an average of one time per day or
higher.
4 / ·The student’s plan involves dealing with scheduled, but infrequent interventions, moderate preventative strategies, exclusionary
time-out, contingent separation, or physical/mechanical restraint occurring in less than 3 times per week or cyclical patterns
requiring the need for high levels of support intervention
3 / ·The student’s plan doesn’t result in removal from the classroom or restraint procedures, but involves strategies for dealing with
non-aggressive, disruptive, attention seeking behaviors, such as token economies & response cost systems (e.g. student
break).
2 / ·The student’s plan is maintenance in nature and/or may involve providing a protective device, but no other interventions or
support beyond what is provided to students who don’t have enhanced staffing is needed.
1 / ·The student doesn’t require a behavioral program or needs behavioral support beyond what is provided to students who don’t
have enhanced staffing.
6. /

BEHAVIOR PLAN SCALE (continued)

The student has a comprehensive behavioral intervention program, which includes staff involvement and/or frequent removal of the student(s) from the classroom. / Yes No
Describe if a behavioral plan has been developed which utilizes intensive staff time & identifies the amount of time directly related to this student including removal of the student from the classroom & ranking behavior(s) (required):
______
______
List environmental modifications & interventions previously implemented (required):
______
7. /

MEDICAL TREATMENT SCALE Please check the box that most accurately describes the complexity & time required for in-school medical treatment.

5 / ·The student needs continuous supervision to maintain health and/or multiple medical treatments per day.
4 / ·The student needs partial supervision & multiple treatments per day.
3 / ·The student receives multiple treatments per day with no extra supervision required.
2 / ·The student has occasional medical treatments during the school day.
1 / ·The student has no medical treatments or support services at school.
Does the student require 1 or more of the following due to medical needs (i.e., tracheotomy, oxygen, suctioning, tube feeding assistance)? Is daily in-school medical treatment is needed for the student health & medical safety? / Yes No
Indicate the medical needs & ranking for this student (required):
______
______
7. /

MEDICAL TREATMENT SCALE (continued)

List environmental modifications & interventions previously implemented (required):
______
8. /

STAFF TIME SCALE

5 / ·Severe-student needs continuous supervision to remain safe, to address target behavior, or to maintain health.
4 / ·Frequent-student needs frequent supervision to remain safe, to address the target behavior, or to maintain health.
3 / ·Moderate-approximately 50% of the time the student requires to remain safe, to address the target behavior, or to maintain
health.
2 / ·Occasional-student has cyclical or isolated situations producing the need for supervision to remain safe, to address the target
behavior, or to maintain health.
1 / ·Mild-student’s need or staff time doesn’t exceed that provided for other students who don’t require enhanced staff support.
Describe the level of staff time needed for this student: ______
Does the student require staff involvement with student outside of school hours for medical treatment consultation, coordination with Community Mental Health, courts, home visits, behavioral treatment meetings, and/or hospitalizations? / Yes No
Explain & rank staff’s additional time utilized to assist in this student’s needs:
______
______
9. /

SUPPLEMENTAL STAFF INVOLVEMENT SCALE

5 / ·The staff needs to be involved in frequent staffings, psychiatric consultations, physician’s appointments, court appointments,
child/family services, home visits, behavioral treatment meetings in addition to school at least 6 or more times per month.
4 / ·The staff needs to be involved 4-5 times per month with additional student needs.
3 / ·The staff needs to be involved 2-3 times per month with additional student needs.
2 / · The staff needs to be involved 1 time per month with additional student needs.
1 / ·The staff are not involved in meetings outside of the regular school hours.
10. /

SUPPLEMENTAL STAFF INVOLVEMENT SCALE (continued)

The classroom has the presence of multiple and/or severe medical care plans. List the students with medical care plans (required):
______
______
The classroom has multiple students demonstrating aggression. List students, concerns, & support needed (required):
______
The classroom has multiple students with disruptive behavior. List students, concerns, & support needed (required):
______
______
The classroom has multiple students with behavioral plans. List students, concerns, & support needed (required):
______

Enhanced Staffing Worksheet: 08-24-06

CURRENT STAFF PATTERN

TEACHER
NAME / SURVIVAL / AGGRESSIVE
DESTRUCTIVE / DISRUPTIVE / BEHAVIOR PLAN / MEDICAL / STAFF TIME / SUPPLEMENTAL TIME / TOTAL

ENHANCED STAFFING MATRIX

Mild Extreme

1 2 3 4 5

SCORING MATRIX If team is in consensus that one area is all one, this area will not be included.

Multiple Students Composite:

2 students >35 pts. = 1 enhanced staff

4 students > 70 pts. = 2 enhanced staff

Individual Student Composite:

22 pts. or above = 1 enhanced staff

Medical Composite:

Physician or nurse recommended

NAME / SURVIVAL / AGGRESSIVE
DESTRUCTIVE / DISRUPTIVE / BEHAVIOR PLAN / MEDICAL / STAFF TIME / SUPPLEMENTAL TIME / TOTAL

Enhanced Staffing Matrix: 08-24-06