August 2009
Saluda County Public Schools
Student Support Team Checklist for Referral
Student______School______
SST Contact______
Does the student currently have a 504 plan? YES NO
In File Missing NAForm / Document
______Screening Permission Letter
______Grades from current and previous school years Current year report card should be most recent / If nine weeks grades do not accurately reflect student’s
performance, include daily grades too.
______Standardized assessments scores (Observation survey, MAP).
______Discipline detail
______Student’s class schedule Middle and high school only
______209 Educational History/ Focus of Concern
______210 Intervention Plan
______213 Vision, Hearing, and Speech Assessments Must be less than 8 months old
______214 Student Observation Form Required for LD and ED referrals
______216 Social, Health, Developmental, and Educational History
______217 Parent Invitation letter
______217A Invitation Response letter
______219 Anecdotal Records Required for ED referral
______222 Medical Report Required for OHI and OI
______Judgmental Statement required for OHI and OI
______270 Conference Minutes (or equivalent) May be more than one, Include all
Suspected Disability
___ Autism___ Deaf-Blindness___ Deaf and Hard of Hearing
___ Emotional Disability___ Mental Disability___ Multiple Disabilities
___ Orthopedic Impairment ___ Other Health Impaired___ Developmental Delay
___ Specific Learning Disability___ Visual Impairment___ Traumatic Brian Injury
___ Speech/Language Impairment
SALUDA COUNTY SCHOOLS
404 N. Wise Road
Saluda, SC29138
Phone: (864) 445-8441
Fax: (864) 445-9598 Setting the Standard
Dr. David Mathis Mr. Ferlondo Tullock
Superintendent Director of Student Services
Permission for Screenings
Dear ______,
Your child, ______, has been referred to the Guidance Department due to academic or behavioral difficulties that are impacting his/her academic progress. With your signature, you give permission for the school to conduct hearing/vision/speech-language/ and/or behavior screenings. Please complete the enclosed Social, Health, Developmental, and Educational History form.
□Hearing/Vision□Behavior
□OT/PT□ Speech-Language
The screening will evaluate the following areas: basic concepts, speech-language, motor skills, vision, hearing, and social-emotional functioning. Immediately following the screenings, you will be asked to meet with the Student Support Team (SST). You may bring other individuals with you who have knowledge or special expertise regarding your child. The team will review the results of the screenings, and any other information you have provided, and then decide whether more information and/or evaluations are necessary. If evaluation is recommended, the purpose of that evaluation will be to determine whether your child is a child with a disability and his/her educational needs. If further evaluation is recommended, that evaluation will not be conducted without your informed, written permission. If you request evaluation and that request is denied, the school district will provide you with a written explanation of why we refused to evaluate your child. The screening and any further evaluations will be provided at no cost to you.
Please check one:
______I give permission for the school to conduct the listed screenings for the named student.
______I do not give permission for the school to conduct the listed screenings for the named student.
______
Parent/Guardian’s name Date
______
AddressPhone Number
______
Parent/Guardian’s Signature
Should you have any questions, please contact your child’s School Counselor.
Saluda CountySchool District One
Educational History / Focus of Concern
NOTE: Please do not leave anything blank.
Child______DOB______School______
Current grade______Grades repeated______Grades administratively assigned______
Frequent school moves?______If yes, list schools by grades attended.______
______
Attendance issues this school year?______Previous years?______
Frequent tardies this school year?______Previous years?______
Does the child speak a foreign language?______Enrolled in ESOL program?______
Do the parents speak a foreign language?______
Does the child have an IEP for speech-language?______Speech therapist______
Has the child ever received services through the ESOL program?______Currently?______
Does the child have a 504 plan?______If yes, for what disability?______
Has the child been evaluated previously for special education?______Contact Pat in the special ed. dept. at 445-8441 or
Has the child been referred previously to SST?______
Medical issues______
Parental/family issues______
Strengths______
Reasons for poor grades: (Check all that apply.)
____ Doesn’t complete testsOther:______
____ Poor test grades______
____ Doesn’t complete homework______
____ Doesn’t complete classwork
____ Poor classwork grades
Does the child show atypical regression following breaks in instruction?______If yes, explain.______
______
Child’s level of effort______Child’s level of frustration______
Child’s response to poor grades, correction, etc.______
Does the child attend special programs or received private tutoring outside of the normal school day?______If yes, explain.______
Have the parents been informed of the educational focus of concern? Yes No
Dates and modes of contacts. i.e. Notes home, phone calls, conference.______
______
______
Parent’s response to poor grades, notes home, conferences, etc.______
______
Other relevant information______
WEAKNESSES / AREAS OF CONCERN
NOTE: Check any item that is a significant concern. Write 1 and 2 by your top two concerns for all areas combined. Do not write in a 1 and 2 for each area. These top two concerns should be the ones that if they were resolved or improved, you feel that you would see improvement in the others areas of concern.
Reading
___Text Level ______End of grade Text Level ______
___ Phonetics______Phonemic awareness______
___ Fluency______
___ Vocabulary______
___ Comprehension: ___Details ___ Main idea ___Sequence ___Inferences ___Conclusions
___Predictions ___Context clues ___Discrepant from listening comprehension
___ Spelling______
Written Expression
___ Copying from board___ Copying from book___ Letter formation
___ Reversals___ Spacing___ Capitalization
___ Punctuation___ Fluency / speed___ Grammar
___ Sequencing of events___ Providing details___ Staying on topic
___ Organization of ideas___ Can express ideas orally but not in writing
Other______
Oral Language
LISTENING COMPREHENSION
___ Poor receptive vocabulary___ Needs things reworded
___ Becomes confused if things are reworded___ Misunderstands all of what was said
___ Only understands part of what was said___ Asks for repetition
___ Asks questions that are tangentially related___ Repeats to self what was just heard
___ Difficulty conversing with adults___ Difficulty conversing with peers
___ Doesn’t understand innuendo, sarcasm, etc.___ Misinterprets or ignores nonverbal cues
___ Other______
ORAL EXPRESSION
___ Poor expressive vocabulary___ Difficulty relating own ideas
___ Uses gestures to substitute for words___ Difficulty with word retrieval
___ Listener needs context in order to understand ___ Relates things out of sequence
___ Has difficulty summarizing or getting to the point___ Speaks in single words only
___ Speaks in phrases only___ Poor grammar
___ Talks rapidly and excessively___ Avoids talking in front of others
___ Stutters or repeats wordsOther______
Math
___ One-to-one correspondence___ Shapes___ Measurement
___ Money___ Time___ Reversals
___ Addition___ Subtraction___ Multiplication
___ Division___ Fractions___ Word problems
___ Tables, graphs___ Sequencing___ Estimation
Other______
Miscellaneous and Emotional / Behavioral
___ Eating___ Toileting___ Hygiene
___ Fine motor skills___ Gross motor skills___ Left-handed
___ Short-term memory___ Working memory___ Long-term memory
___ Impulse control ___ Task persistence___ Frustration tolerance
___ Attention during instruction___ Attention while working___ Organization
___ Distraction by auditory stimuli___ Distraction by visual stimuli___ Easily overstimulated
___ Bothered by loud noises___ Bothered by certain textures___ Doesn’t like to be touched
___ Adjusting to changes in routine___ Underactive___ Overactive
___ Periods of transition___ Unstructured times___ Cries easily
___ Poor self-esteem___ Worries excessively___ Shy, withdrawn
___ Immature___ Inappropriate emotional affect___ Physical complaints
___ Sudden mood changes___ Self-injury___ Self-derogatory comments
___ Prefers adults to peers___ Repetitive, ritualistic behavior___ Seeks attention from peers
___ Seeks attention from adults___ Doesn’t like to be singled out___ Verbally aggressive
___ Physically aggressive___ Sexually inappropriate behavior___ Manipulative
Other______
______
______
Completed By Date
In addition to this form, the Pre Team should gather and review the information listed below. If the child is later presented to the Student Support Team, the information listed below must be submitted along with this form.
-Copies of grades for this year and last year
-Work samples
-Copy of district-wide standardized test scores (summary sheet of labels is sufficient, exs. PACT, MAP, CogAt, etc.)
-Copy of discipline detail (if student has discipline issues)
-Form 208 “Parent Referral to Student Support Team” (if applicable)
-Form 216 “Social, Health, Developmental, and Educational History”
-Printouts from any computer programs used with the child (ex. CAI)
-For ESOL students, DIBELS printouts
-For ESOL students, results of placement and diagnostic tests (San Diego Quick, Dominie, Read Naturally, etc.)
-Present levels of performance in areas of concern (Be prepared to complete top of form 210 when meeting with SST)
-Any other relevant information or documentation
DOCUMENTATION OF INTERVENTIONS
NOTES: This section is used to document interventions that occur prior to referral to the Student Support Team. This form can be used to document interventions attempted prior to completing the form and interventions that are recommended by the Pre Team. The concerns / problems listed here should correspond to your top two in the previous section. Include both interventions that have and have not resulted in progress. If the information is available, provide specific data when reporting the results of the interventions. For example, “Reading fluency increased from 40 to 50 words per minute.”
Parents were notified on ______(date) ______(in person, by telephone, or via letter) by ______(staff member).
Pre Team members who participated in developing and/or reviewing these interventions:
______
______
______
Problem / Concern #1______
______
Date Date
Interventions Begun Ended Results
______
______
______
______
______
______
______
Problem / Concern #2______
______
Date Date
Interventions Begun Ended Results
______
______
______
______
______
______
SaludaSchool District One
Intervention Plan
Student______School______
Date Developed______Projected Date of First Review ______
Precise description of academic weakness / concern (One concern per form, No more than two forms per student):
______
______
Present level or frequency on date plan was developed (Must be measurable and sensitive to change):
______
______
Present level or frequency for an average student in the same class:______
______
Goal level or frequency after intervention period (Although it might not be equivalent to the rest of the class, what would be considered significant improvement and evidence of success of the intervention?):
______
I N T E R V E N T I O N S
Areas to consider when intervening: environment, instruction, curriculum, parents.
Intervention / Accommodation Date Begun Date Ended
______
______
______
______
______
______
______
______
______
______
______
TEAM MEMBERS WHO PARTICIPATED IN DEVELOPING ORIGINAL PLAN
Signature Title Date
______
______
______
______
______
______
------
Actual date of first review:______
Present level or frequency after implementation:______
______
Recommendation:
_____ Continue plan as written and review again by______
_____ Modify plan and review again by______(Note changes in intervention section)
_____ Refer for 504
_____ Have meeting to determine whether evaluation is warranted
_____ Drop from SST but continue interventions
_____ Discontinue plan and drop from SST
_____ Other______
------
Actual date of second review:______
Present level or frequency after implementation:______
______
Recommendation:
_____ Continue plan as written and review again by______
_____ Modify plan and review again by______(Note changes in intervention section)
_____ Refer for 504
_____ Have meeting to determine whether evaluation is warranted
_____ Drop from SST but continue interventions
_____ Discontinue plan and drop from SST
_____ Other______
August 2009
Saluda County Public Schools
Vision, Hearing, and Speech-Language Assessments Revised 2009
______
Student’s Full Name Teacher Date of Birth School
______
August 2009
VISION
______Initial Assessment ______Reassessment
Distance Vision
Uncorrected Corrected
Right (OD)______
Left (OS) ______
Both (OU)______
Near Vision
Uncorrected Corrected
Right (OD)______
Left (OS) ______
Both (OU)______
Disposition:
______No further action needed at this time
______Referral made______
______
Results of Reassessment: ______
______
Examiner:______
Date:______
STUDENT MUST PASS VISION ASSESSMENT
PRIOR TO REFERRAL FOR PSYCHOLOGICAL
EVALUATION. 20/40 IS PASSING; ANYTHING
ABOVE WOULD NEED REASSESSMENT AND/OR A PHYSICIAN’S STATEMENT.
SPEECH - LANGUAGE
Area of Assessment Pass Fail
Oral Peripheral ______
Articulation ______
Voice ______
Fluency ______
Receptive Language ______
Expressive Language ______
Disposition:
_____ No further action indicated at this time
_____ Schedule for comprehensive evaluation
_____ Currently enrolled in speech therapy
_____ Other______
______
Comments: ______
______
______
Clinician:______
Date: ______
HEARING
Initial Assessment Right Left
1000 Hz (at 20dB) Pass / Fail Pass / Fail
2000 Hz (at 20dB) Pass / Fail Pass / Fail
4000 Hz (at 20 or 25dB) Pass / Fail Pass / Fail
Date:______
Reassessment Right Left
1000 Hz (at 20dB) Pass / Fail Pass / Fail
2000 Hz (at 20dB) Pass / Fail Pass / Fail
4000 Hz (at 20 or 25dB) Pass / Fail Pass / Fail
Date:______
Reassessment Right Left
1000 Hz (at 20dB) Pass / Fail Pass / Fail
2000 Hz (at 20dB) Pass / Fail Pass / Fail
4000 Hz (at 20 or 25dB) Pass / Fail Pass / Fail
Date:______
Disposition:
______No further action indicated at this time
______Referral made______
______
______
Examiner: ______
STUDENT MUST PASS HEARING ASSESSMENT PRIOR TO REFERRAL FOR PSYCHOLOGICAL TESTING.
August 2009
SaludaCountySchool District One
Student Observation Record
Student’s Name______School______Grade______
Setting______Activity______
Date______Teacher______Time Period______
Observer______Title______
DIRECTIONS: Read each statement and determine how the student’s behavior compares to the class average.
LESS EQUAL GREATER NOT
THAN TO THAN OBSERVED
Needs instructions repeated______
Is distracted by auditory stimuli.______
Is distracted by visual stimuli______
Daydreams, Stares into space______
Doesn’t persist when frustrated or delayed______
Is fidgety or restless, Produces motion without purpose______
Is out of seat at inappropriate times______
Becomes overly excited or stimulated______
Has difficulty delaying gratification, Cannot wait turn ______
Impulsive, Frequently changes answer______
Needs reassurance or assistance to begin work or to
continue working______
Requires directions given individually______
Oral or written responses are irrelevant to task at hand______
Makes identical errors even after correction______
Materials and belongings are disorganized______
Written work contains omissions, reversals, and/or
careless errors______
Poor handwriting (letter formation, staying on lines,
spacing, etc.)______
Has difficulty copying correctly from board or book______
Has difficulty with fine motor skills (holding pencil,
tying shoes, opening containers, etc.)______
LESS EQUAL GREATER NOT
THAN TO THAN OBSERVED
Has difficulty expressing self orally ______
Misunderstands what has been said ______
Does not pick up on social cues during conversation______
Invades others’ personal space______
Touches others inappropriately
Explain______
Uses profanity or inappropriate gestures______
Engages in silly, immature behavior______
Seeks attention from adults______
Seeks attention from peers______
Becomes emotionally upset over academic work______
Becomes emotionally upset during social interactions ______
or when asked to follow a rule
Becomes stubborn / uncooperative / resistant while
completing academic work______
Becomes stubborn / uncooperative / resistant during
social interactions or when asked to follow a rule______
Is withdrawn, quiet______
Has difficulty adjusting to changes in routine______
Affect is inappropriate or inconsistent with reported
feelings______
Is physically aggressive toward self
Explain______
Is verbally or physically aggressive toward others
Explain______
Makes negative comments about self, Puts self down______
Makes somatic complaints______
Perfectionistic, overly concerned with details or order______
______
______
______
Additional comments:______
______
SaludaCountySchool District One
Social, Health, Developmental, and Educational History
Child’s Full Name ______Date of Birth______Race______
Mailing Address______Street______
Home Phone #______Cell Phone #______Work #______
Social Security Number______Grade______Grades Repeated______
School______Other Schools Attended______
SOCIAL
MOTHER / FEMALE GUARDIAN IN HOME FATHER / MALE GUARDIAN IN HOME
Name______Name______
Relationship to Child______Relationship to Child______
Age______Marital Status______Age______Marital Status______
Level of Education Completed______Level of Education Completed______
Occupation______Occupation______
Employer______Employer______
LIST PARENTS NOT LIVING IN THE HOME
Name Relationship Contact/Involvement with Child
______
______
LIST BROTHERS AND SISTERS (Attach additional page if necessary.)
NameAge Sex Living in home?
______Yes No
______Yes No
______Yes No
______Yes No
LIST OTHER PERSONS WHO ARE CURRENTLY LIVING IN THE HOME NOT NAMED ABOVE
NameAge Sex Relationship
______
______
Have any of the child’s biological parents, grandparents, and / or siblings ever received special education services?
( ) Yes ( ) No If yes, please explain.______
______
What is the primary language spoken in the home? ___ English Other______
What is the student’s primary language? ___ English Other______
Describe any cultural factors which might affect your child’s social and/or academic functioning.______
______
How does your child get along with others at home?______
Has your child ever had previous psychological or educational evaluations? By whom?______
Has your child ever been involved with any outside agencies such as Mental Health, DJJ, or DDSN? If yes, please list. ______
HEALTH
Did the mother receive prenatal care from a physician? ( ) Yes ( ) No
Did the mother experience any of the following during pregnancy or delivery?
___ High blood pressure ___ Excessive vomiting___ Use of illicit drugs (marijuana, cocaine, etc.)
___ Toxemia ___ Physical injury ______
___ RH incompatibility ___ Use of forceps during delivery___ Prescribed medication______
___ Measles ___ Illness
___ Gestational diabetes ___ Use of tobacco productsOther ______
___ Anemia ___ Use of alcohol ______
Was the baby born prematurely? ( ) Yes ( ) No If yes, how many weeks premature?______
What was the baby’s weight at birth? ______pounds ______ounces
Did the baby experience any complications at birth?
___ Lengthy hospital stay___ Heart problems
___ Physical defects___ Use of incubator
___ Breathing problems___ Use of forceps during delivery
___ Oxygen deprivation ___ Other______
List any prescription medications which your child is currently taking.
Name of Medication Dosage Purpose
______
______
______
What is the name and city of your child’s physician?______
Please check all that apply to your child. For those checked, please provide the date or age at which it occurred or began.
___ Head injury______Tuberculosis______
___ Seizures______Fever of 104 or higher______
___ Coma______Frequent ear infections______
___ Stroke______Allergies______
___ Cerebral palsy______Hearing problems______
___ Meningitis______Vision problems______
___ Encephalitis______Asthma / Respiratory problems______
___ Brain tumor______Heart problems______
___ Shaken Baby Syndrome______Digestive problems______
___ Migraine______Rheumatic Fever______
___ Fetal Alcohol Syndrome______Measles______
___ Lead poisoning______Complications from chicken pox______
___ Cancer______Emotional/Behavioral problems______
___ Cystic Fibrosis______Other______
How would you describe your child’s present health? ( ) Poor ( ) Fair ( ) Good ( ) Excellent
Typically, how many hours per night does your child sleep?______
Does your child have any sleep problems or disorders (i.e. sleep apnea, night terrors, sleep walking, difficulty going to or staying asleep)?______
DEVELOPMENTAL
Place a check beside any area in which your child had significant difficulty as an infant and/or toddler.
___ Feeding ___ Motor skills ___ Weight / Failure to thrive___ Excessive crying
___ Separating from parents ___ Temper tantrums ___ Being held / affection
Compared to most other children, how quickly did your child develop the following skills? Please circle your answer.
Rolling over Faster than Average Slower than
Crawling Faster than Average Slower than
Sitting alone Faster than Average Slower than
Walking Faster than Average Slower than
Toilet training Faster than Average Slower than
Staying dry at night Faster than Average Slower than
Feeding self Faster than Average Slower than
Dressing self Faster than Average Slower than
______Faster than Average Slower than
LANGUAGE DEVELOPMENT
1. At what age did your child say his/her first words?______Put words together?______
2. What were your child’s first words?______
3. Does your child appear to hear well? ( ) Yes ( ) No ______
4. Does your child follow directions given orally? ( ) Yes ( ) No ______
5. Do you think your child has a speech or language problem? ( ) Yes ( ) No ______
6. Does your child appear to be aware of any differences in his/her speech? ( ) Yes ( ) No If yes, how does he/she react?
______
7. Has your child ever been evaluated by or received speech-language therapy from any agency or individual? ( ) Yes ( ) No
If yes, by whom?______
8. Are there any known conditions affecting his/her tongue, palate, nose, throat, vocal cords, or ears (i.e. cleft palate, vocal
nodules, etc.?) ( ) Yes ( ) No ______
EDUCATIONAL
Does or did your child attend preschool or daycare? ( ) Yes ( ) No
When your child has an academic problem at school, how do you deal with it at home?______