First Middle Last / DOB: ______/ School Year: ______/ Grade: ______/ NCWISE #: ______
Teacher/Team: ______/ School: ______/ Race :______
Sex: Male Female / Retentions Yes No Grade(s)______
Parents/Guardians:______
Address:______/ Phone(s): Hm______Wk______Cell______
Email:______
Identified EC or 504: ______
Category or Condition (includes speech)
Extend II Yes No If yes, what year(s)?______
Content Area______/ ESL Services: Yes No / IEP/ESL/504 Modifications: Yes No / A previous SSP?: Yes No
Iredell-Statesville Schools Student Support Plan, K-2
Record Review/Student Data
I. Provide the following data as applicable for student (see flowchart for directions to access)Days absent/tardies from current and previous three years
Current___/____ Previous ____/____ Previous ____/_____
Grades from most recent report card: Date:______
Math______ELA______SS______S______
Final report card previous grade level:
Math______ELA______SS______S______
From DASH report, record the following scores for students:
K-2nd Math: Baseline______PA______PA______PA______
Class Avg. Baseline ______PA ______PA ______PA______
K-2nd DRA Kindergarten______1st ______2nd______/ III. / Have parents been notified of strategies provided to student?: Yes No
Conference Phone Written Date:______Summary:
______
IV. / Attach Copy of Literacy Card
II. / Does a previous Psychological/EC Eval/Group IQ exist? Yes No
If so (instrument/date/results) ______
______
Significant Health/Medical information:______
______
Other Classroom or Assessment Data: / Behavior/ Discipline Concerns (attach discipline record if a concern): / Relevant social, environmental, cultural factors:
Teacher - Strengths of Student: / Parent - Strengths of Student: / Student - Strengths of Student:
Core Instruction and Remediation
Classroom Strategy Development and Parent Conferences
Specific academic and/ or behavioral gaps specifically indicated by the data:State the student’s goal to address identified Gap area:
How will the goal be measured? How often? With what instrument?
Strategy(ies) to be used in the Core:
If remediation is being utilized, define strategy(ies), content, duration and embedded assessment:
Date of parent contact/conference:
Core / Teacher will:
Teacher Signature: ______/ Parent will:
Parent Signature: ______/ Student will:
Student Signature: ______
Remediation / Teacher will:
Teacher Signature: ______/ Parent will:
Parent Signature: ______/ Student will:
Student Signature: ______
Date/Time/Type of next communication: / Date to be reviewed:
Is vision screening current within nine months?
If not, then obtain. / Vision screening: Date______pass/fail Far : R20/_____ L20/_____ Near: R20/____ L20/____
Retest: Date______pass/fail Far : R20/_____ L20/_____ Near: R20/____ L20/____
Strategy Adjustments and Monitoring/Parent Conference
Conference Contact Date:______/ Results from 1st cycle of strategies (imbedded pre and post/ curriculum-based measure):Core / Teacher will:
Teacher Signature:______/ Parent will:
Parent Signature: ______/ Student will:
Student Signature:______
Remediation / Teacher will:
Teacher Signature: ______/ Parent will:
Parent Signature: ______/ Student will:
Student Signature: ______
Date/Time/Type of next communication: / Data and date to be reviewed:
Conference Contact Date:______/ Results from 2nd cycle of strategies (imbedded pre and post/ curriculum-based measure):
Core / Teacher will:
Teacher Signature:______/ Parent will:
Parent Signature: ______/ Student will:
tudent Signature:______
Remediation / Teacher will:
Teacher Signature: ______/ Parent will:
Parent Signature:______/ Student will:
Student Signature: ______
Date/Time/Type of next communication: / Data and date to be reviewed:
(Copy and paste additional Adjusting and Monitoring sections as needed)
Yes, this plan has been developed, discussed, and reviewed with grade level team. (team members sign below)
______
______