Individual Problem Solving Form

Appendix A:

MTSS Forms

Individual Problem Solving Form

Student name: ______Grade: ______Date: ______

Problem Solving Team Members: ______

Area of concern: / Behavior / Reading / Math / Writing / Other (describe)
______
(circle primary area)

Step 1: Problem Identification (What is the problem?)

Student present level of performance:
Expected student level of performance:
Magnitude of discrepancy:
Problem Definition:
Replacement behavior or target skill:

Step 2: Problem Analysis (Why is it happening?)

Domain / Relevant Known Information
Instruction
(e.g. pacing, corrective feedback, explicitness, opportunities to practice, engagement, etc.)
Curriculum
(e.g. skills taught, instructional materials, scope & sequence, expected outcomes, previous interventions, etc.)
Environment
(e.g. room setup, peer influence, expectations and rules, behavior management system, etc.)
Learner
(e.g. academic skills, behavioral concerns, etc.)

Based on the above information (instruction, curriculum, environment, & learner) why do you think the current problem is occurring and what is the predicted result of an appropriately matched intervention?

Problem Hypothesis: The problem is occurring because ______

MTSS-1-Individual Problem Solving Form

Prediction: The problem will be reduced if ______

Data used to validate hypothesis: ______

______

Do you have enough information to complete the problem analysis and develop an intervention? If no, what else is needed and who will be responsible for collecting it? ______

Step 3: Plan Development (What are we going to do?)

Target skill: ______

Goal (This intervention will be successful if…): ______

What will be done?
(actions taken, target skills taught, curriculum/materials used) / How will it be done?
(instructional strategies, etc.) / Who is responsible? / Where will it occur? / How often? (days per week & min. per day) / Group size?
Progress monitoring plan / What materials will be used? / Who is responsible? / How often? / Decision Rule?
Fidelity plan / What data will be collected? / Who is responsible? / How often will it be collected? / Minimum standard for fidelity?

Follow up date: ______MTSS-1-Individual Problem Solving Form

Step 4: Plan Implementation & Evaluation (Did it work?)

*Attach graphed data

Attendance: / # of intervention days attended: / Total # of intervention days: / % of intervention sessions attended
Intervention fidelity data:
Minimum standard met? Yes No
Student rate of progress: / Peer/Expected rate of progress:
 Less progress than expected/peers  More progress  Same progress
Student level of performance: / Expected student level of performance:
Magnitude of discrepancy:
Less discrepant than expected/peers  More discrepant  Same level of discrepancy
If less discrepant/good progress: Continue current intervention? Yes No
Fade intervention support? Yes No
If more discrepant/poor progress: Was the intervention implemented as planned? Yes No
Do we need to intensify supports? Yes No
Refer for special education evaluation? Yes No
If discrepancy the same/average progress: Was the intervention implemented as planned? Yes No
Do we need to intensify supports? Yes No
Refer for special education evaluation? Yes No
Comments/Actions/Next Steps:

MTSS-1-Individual Problem Solving Form

Washoe County School District / STANDARD TREATMENT PROTOCOL/GROUP PROBLEM SOLVING FORM-Instructional Planning Form

MTSS-2 Standard Treatment Protocol/Group Problem Solving Form

This form may be used in replacement of the Individual Problem Solving (MTSS-1) when the Intervention Assistance Team has reviewed school wide data and found converging evidence (student grades and 3 sources of testing data) to suggest a need for a standard treatment protocol based intervention to be delivered to a group of students. Individual goals and graphs must be kept for each participating student. Participation rates (attendance) of each student in the group intervention must be documented. Decisions regarding the success of the intervention are to be made on an individual student basis. Information form this form can be inputted within the MTSS tab in Infinite Campus.

Team Meeting Date: ______Area of Concern: __ Reading __ Math __ Writing __ Behavior

Student Name: ______(complete 1 form for group, make copies, and write individual student names on one form for each participating student)

PROBLEM IDENTIFICATION
List the sources of data reviewed by the team for selection of students / List the criteria determined for inclusion in the group intervention
BRIEF PROBLEM ANALYSIS
Describe the common instructional need identified among this group of students
PLAN DEVELOPMENT
GOAL SETTING

• On each individual student progress monitoring graph, list student baseline score and goal

INTERVENTION
Brief Description: / When:
Description of Needed Materials: / Where:
Intervention Implementer: / How Often:

• Intervention Plan is attached which describes the intervention activities in detail

MEASUREMENT SYSTEM
Data Collection System: / Frequency of Data Collection:
Data Collector: / When will Data be Collected?
What Will Be Recorded?
Decision Making Rule
Slope/Trend Analysis Level of Performance Consecutive Data Point Rule Other:______

Intervention Start Date: ______Review Date: ______Time: ______Place: ______

Nevada Dept. of Educ. Policy Statement provided to & signed by parent. Date: ______

Infinite Campus has been updated to reflect student’s supports within MTSS tab.

Student: ______Grade: ______Date: ______

Teacher: ______School: ______

Activity
Focus or Skill Teaching Strategy / Materials / Arrangements / Time / Motivational
Strategy

Student: ______Hannah______Grade: ______3rd______Date: ____9/15/08______

Teacher: ______Mrs. Joseph______School: _____Anytown Elementary______

Activity
Focus or Skill Teaching Strategy / Materials / Arrangements / Time / Motivational
Strategy
Oral reading / Round Robin
Choral Responding
Teacher Modeling / Better Reading Series
Book III
Literature Books / Teacher-led instruction
Small Group (5 students) / 9:00 to 9:45 each day / Teacher praise
School-wide recognition system
Silent Reading / Modeling
Read for 20 minutes each night at home / Better Reading Series Book III
Literature Books / Independent / 12:00 to 12:30 each day / Teacher praise
“Rocket Chart” of pages read.
Vocabulary
-definitions
-spelling / Teacher-led Instruction; modeling; use words in sentence; use keyword strategy; play spelling games / Vocabulary list from Better Reading Series Book III / Teacher-led; whole class (20 students)
Practice with peer / 20 minutes daily
10 minutes daily / Teacher praise
Whole class chart of progress
Phonics skills/decoding
-vowel sounds
-blends / Teacher-led instruction with choral responding
Independent practice and teacher feedback / Better Reading Series Book III skills exercises and worksheets / Teacher-led; whole class (20 students)
Independent / 20 minutes daily
15 minutes 2x weekly / Teacher praise
Stickers
Comprehension
-literal facts
-inference
-opinion / Teacher-led discussion; question and answer; students take turns / Better Reading Series Book III
Study guides and skills book / Teacher-led; whole class (20 students) and small group (5 students) / 15 minutes daily after oral reading time / Teacher praise

Student Name: Date: MTSS-3

WCSD Multi-Tiered Systems of Support Case Review

(Required for Consideration of Special Education Referral)

STANDARD

Directions: Check “YES” if the component is documented and meets the standard. Check “NO” if not.

/ Tier 2 / Tier 3
YES / NO / YES / NO
Problem Identification

• An initial problem was defined in observable measurable terms and was quantified.

• Documented data from at least 3 sources converge to support the problem statement.

• Student baseline data in the area of concern is collected using a measurement system with sufficient technical adequacy for ongoing frequent measurement, and includes a minimum of 3 data points with standardized procedures for assessment. Baseline data are graphed.

Problem Analysis

• Data from a variety of sources (RIOT) and domains (ICEL) were collected to consider multiple hypotheses for the cause of the identified problem. These data are documented.

• A single hypothesis for the cause of the performance gap was selected. At least 3 pieces of data converge to support this hypothesis. At least one of these is quantitative.

Plan Development

• A data-based goal was established that describes the learner, conditions (time and materials for responding), expected performance, and a goal date. The goal is indicated on a graph.

• The intervention selected meets federal definition of scientifically research-based intervention. The selected intervention directly addresses the specific identified problem and the hypothesis for the cause of the problem.

• A written intervention plan was clearly defined that explicitly describes what will be done, where, when, how often, how long (per session), by whom, and with what resources.

• A written description of the progress-monitoring plan was completed and includes who will collect data, data collection methods, conditions for data collections, and schedule.

• A decision making rule was selected for use.

• A plan evaluation meeting was set for no more than 8 weeks after the plan was established.

Plan Implementation

• The Intervention Plan was implemented as specified on Form MTSS-1. Implementation verified during administrative/IAT “walk-through” or other observations.

• Data were collected and graphed as stated in intervention plan. The required number of data points was collected.

Plan Evaluation

• Team documented agreement that the plan was carried out as intended.

• Team determined and documented whether the pre-intervention performance gap decreased, increased, or stayed the same during the plan implementation phase.

• Team decided to continue the plan unmodified, modify the plan, or terminate the plan and develop a new plan. Team documented this decision.

Special Education Referral Guidelines – (to be considered only when all other boxes indicate “YES”)
A. After implementation of at least two scientifically research-based interventions, student’s slope of growth continues to be below grade level target slope rates.
B. After implementation of at least two scientifically research-based interventions, student’s level of performance continues to be at the 10th percentile or below compared to national averages.
C. Team determines that the student demonstrates educational needs that require resources more intensive than can be provided in general education.

Team Signatures:

Administrator School Psychologist

Intervention ImplementerCounselor

Parent Team Member

PERMISSION FOR REVIEW

I, ______, hereby give my permission for

Parent/Legal Guardian/Surrogate

the Washoe County School District to respond to a request for assistance

for ______.

Name of Child

In giving my permission I understand that any or all of the following may occur:

1)Review of relevant records (releases of information will be included);

2)Interviews with myself or caregiver;

3)Observation(s) of my child; and/or

4)Assessment (such as curriculum-based, screening, and other appropriate measures to determine interventions).

I further understand and agree that the information collected by the school district will then be reviewed and the team will develop an intervention plan and designate the resources needed to implement these interventions.

A disability is not suspected at this time. However, if the team suspects that my child has a disability, my permission will be obtained for a multi-factored evaluation.

______

Name of Parent/Legal Guardian/Surrogate

______

Signature

______

Date

PERMISO PARA REVISION

Yo, ______(Padres, Guardián Legal/Portador/a), doy mi permiso al Distrio Escolar Del Condado de Washoe para que responda al pedido de asistencia para ______(Nombre del Niño).

Al dar mi permiso entiendo que todos o algunos de los siguientes pueden suceder:

1) Reviso de archives reveladores (sediment de información sera includia);

2)Entrevistas conmigo o su cuidador:

3)Observaciones de mi niño/a; y/o

4)Evaluación (tal como curricula basada en investigaciones, y otras medidas apropiadas para determiner intervenciones.

Entiendo que mas adelante y estoy de acuerdo que la información obtenida por parte del distrito escolar sera revisada y el equipo desarrollara un plan de intervención y designara resursos necesarios para implementar estas intervenciones.

No sospechamos ninguna incapacidad a esta hora. Sin embargo, si el equipo sospecha que mi hijo/a tiene una incapacidad, mi permiso sera obtenido para una evaluación de multifactores.

______

Nombre de los padres/Guardianeslegales/Portador/a

______

Firma

______

Fecha