Name of School

Exemplar Application PowerPoint

Date

PBIS Team Information: 2016-17

Slide # 1 - Demographics

☐Name of school, LEA

☐Address

☐Phone Number (Area) ###-####

☐County

☐Region

Slide # 2 - School Demographics

Grade levels served by school

Student enrollment numbers

Number of faculty/staff members

Ethnicity breakdown

Slide # 3 – PBIS Team Information

☐In-School Coach, with contact information

☐Team members

☐Include role within PBIS team

☐Include position at school

Slide # 4 - Outcome Data- Showing Growth – Academics

☐Achievement data, EOG/EOC scores, math scores, reading scores, etc.

☐Aggregated to over the past three years, at least

☐Explanation of decline in data

Slide # 5- Outcome Data- Showing Growth - Behavior

☐Office Discipline Referral (ODR)*

☐Aggregated over the past three years (at least)

☐Explanation of decline in improvement data

Slide # 6 - Outcome Data- Showing Growth – Additional Data

☐Additional Data: Suspension data, expulsion data, attendance, EC referral data, climate surveys, ethnicity reports, closing the disproportionality gap, bus referrals, staff retention data, etc.

☐Aggregated over the past three years (at least)

☐Explanation of decline in improvement data

Slide # 7 - Referral Process for Supplemental and Intensive Support

☐Referral Process for Supplemental and Intensive Support.

Brief description of the referral process and a visual representation through a table, chart, graph etc.,

Slides # 8 - 10–Tier 1 Implementation

Components to add:

Systems of practice, organizational structures

☐Matrix – Slide # 8

☐Acknowledgement systems – Slide # 9

☐Consequence grids – Slide # 10

☐Others

Slides #11 -12 -Tier 2 Implementation

Components to add:

Systems of practice, organizational structures - Describe two to three Tier 2 evidence based intervention in place. Include how data is collected and used to improve outcomes for students (one slide per intervention)

☐Slide #11– Tier 2 Intervention #1

☐Slide #12 – Tier 2 Intervention #2

Slides # 13 -14 - Tier 3 Implementation

Components to add:

Describe two to three Tier 3 evidence based intervention in place and how data is collected and used to improve outcomes for students (one slide per intervention).

☐Slide #13 – Tier 3 Intervention #1

☐Slide #14 – Tier 3 Intervention #2

Integration of Initiatives - Optional

•MTSS

•Responsiveness to Instruction

•Character Education

•Literacy

•Bully prevention programs

•Classroom strategies

•Problem-Solving strategies (Ex: TIPS)

•Others

District Implementation

(optional)

☐Visibility within LEA, leadership teaming

☐Political support strategies

☐Policy change or integration

☐Training/coaching capacity building

☐Evaluation/assessment for LEA

☐Fidelity of implementation