McGaugh Elementary School Student Success Team (SST) Teacher Input Page 1 of 4

Student: / SST Date:
Grade: / Teacher:

***Instructions: Please type information directly into boxes. Once form is submitted to the School Psychologist/Assistant Principal, an SST meeting will be scheduled. ***

Is the student currently in special education receiving speech services? Yes No

Current concern(s) (Check all boxes that apply):

Listening Comprehension and/or Oral Expression Basic Reading and/or Comprehension Attendance

Written Expression Skills Basic Math and/or Concept Skills Health

Learning Skills (Attention, Focus) Social/Emotional/Behavioral Concerns Fine/Gross motor

Present Levels of Student Performance

What are the student’s strengths?
STANDARDIZED TESTING
CST ELA: / CST Math:

Please describe student’s current performance in all areas below.

Reading/English/Language Arts: (Information could include: concepts about print, phonemic awareness, decoding single and multi-syllable words, reading fluency, comprehension, etc.). Include District Benchmark performance. / RtI Group
Intensive Strategic
Benchmark Enrichment
Start date &
End date:
F&P: (Alpha Level) / Administration Date: / Fluency: / Comprehension:

Below Benchmark Approaching Benchmark Meeting Benchmark Exceeding Benchmark

Writing: (Information could include: spelling abilities, phonetic spelling, ability to write complete sentences/paragraphs, ability to use correct grammar, punctuation and sentence structure, ability to write using his/her own ideas, ability to summarize a text, etc.)

Below Benchmark Approaching Benchmark Meeting Benchmark Exceeding Benchmark

Mathematics: (Information could include: ability to solve computation problems [+ - x ÷], ability to solve word problems, ability to solve problems involving time and money, understanding of algebraic and geometric concepts appropriate to grade level, etc.) Include District Benchmark performance. / RtI Group
Intensive Strategic
Benchmark Enrichment
Start date &
End date:

Below Benchmark Approaching Benchmark Meeting Benchmark Exceeding Benchmark

Behavior : (Information could include: attention to tasks, socialization, task completion, distractibility, following directions, etc.). Include: What do you believe triggers the behavior? (Ex. Non-preferred task, transitions, etc.) How often does the problematic behavior occur? (Ex. 10 times per 20-minute instruction period) When is the behavior most likely to occur? (Ex. after recess, undesirable activity, during transitions)

Participation in RtI

School Year / Grade / Subject / Grouping
ELA Math / Intensive Strategic Benchmark Enrichment
ELA Math / Intensive Strategic Benchmark Enrichment
ELA Math / Intensive Strategic Benchmark Enrichment
HW Regularly Completed: Yes No
20% of the time 40% of the time 60% of the time 80% of the time Almost Always
Dates of previous parent-teacher conferences during current school year:
Interventions implemented as a result:
TEACHER INITIATED INTERVENTIONS: (Check all that have been utilized)
Peer tutor Provide study guide/notes Use of timer
Visual prompts/aids Ongoing small group instruction Modify assignments
Increase verbal/visual directions Increase student choice Modify homework
Preferential seating Break down task into smaller parts Modify tests/assessments
Provide study guide/notes Previous SST
BEHAVIORAL: (Check all that have been utilized)
Counseled with student Contacted parent/guardian Rewarded expected behavior
Changed seat Ignored behavior Used proximity control
Time out or quiet area Teacher modeled positive behavior Referred for counseling
Changed the reward Praise students modeling desired behavior Given own work space
Used behavior contract/level system Provided cues/prompting related to behavior School suspension
Applied consequences/took privileges away Provided systematic feedback about behavior
Additional Previous Interventions/Comments:

Please attach current benchmark data and state testing from Illuminate.