Student Assistance Team Checklist

Student Assistance Team Checklist

Date______Student______Grade______Teacher______

Concerns (circle): Academic Social/Behavior Both

Meeting Purpose: ______

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Meeting Participants (Check all that apply):

____ Principal ____ Parent/Guardian ____ School Psychologist

____ Behavioral Specialist ____ General Ed. Teacher ____ Home/School Support Specialist

____ Curriculum Specialist ____ Special Ed. Teacher ____ Other (please specify)______

Check When Complete /

Problem Identification

/ List all concerns in observable terms (use verbs to describe what the student is doing): ______
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______/ Prioritize:
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/ Define the problem behavior in observable and measurable terms using verbs: ______
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/ Define the appropriate behavior in observable and measurable terms: ______
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/ List the behavioral goal for the problem behavior and/or appropriate behavior: ______
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What are you going to measure?
/ Document and validate the problem behavior. Compare it to the average classroom behavior (collect baseline data). How are you going to collect the data (what method)?
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Who is going to collect the data? ______In what setting? ______

Time of day and duration: ______

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Check When Complete /

Problem Analysis

(After baseline data is collected)
/ List potential Medical Conditions or Stressful / Major Life Events that could contribute to the problem behavior occurring:
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______/ List Actions Taken (assessments/referrals) for concerns: (What will be done? By whom? When? Setting?) ______
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/ Is the problem behavior identified as a Skill Deficit (“can’t do”) or a Performance Deficit (“won’t do”): ______
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______/ Evidence: ______
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/ Using the table below, indicate the settings where the problem behavior is most and least likely to occur. List comments here: ______
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SITUATIONS

/ MOST LIKELY / LEAST LIKELY / EVIDENCE (Check Box)
Teacher Interview / Student Interview / Parent Interview / Record Review / Office Referral / Formal Observation / Informal Observation / CBA / Other (please List)
When/Time of Day?
(e.g., A.M., P.M.)
Where/Setting?
Physical/Instructional Locations (i.e. recess, gym, school bus)
With whom? (e.g. certain peers, teachers, other adults etc.)
What format of activities? (e.g. small group, independent work, lecture, writing tasks)
What is the content or type of task? (e.g. math, reading, science, etc.)
Problem Analysis (continued)

Outcome

Sources of Evidence (Check the box)

Identify what you think causes or motivates the student to engaged in the behavior of concern (check list of sources). What is the student saying with their behavior? / Teacher Interview / Student Interview / Parent Interview / Record Review / Office Referral / Formal Observation / Informal Observation / CBA / Other (list)
What do they GAIN/OBTAIN? (Circle the number)
Attention from peers?
1 2 3 4 5
Very Unlikely Not Sure Highly Likely
Attention from adults?
1 2 3 4 5
Very Unlikely Not Sure Highly Likely
Access to a preferred object or activity?
1 2 3 4 5
Very Unlikely Not Sure Highly Likely
Access to sensory stimulation?
1 2 3 4 5
Very Unlikely Not Sure Highly Likely
What do they ESCAPE/AVOID?
Social interactions with peers and/or adults?
1 2 3 4 5
Very Unlikely Not Sure Highly Likely
Teacher directed activity or task?
1 2 3 4 5
Very Unlikely Not Sure Highly Likely
Sensory stimulation?
1 2 3 4 5
Very Unlikely Not Sure Highly Likely
/ If you have enough evidence to support a hypothesis about the function of the behavior, list it here and prioritize. If you don’t have enough evidence, list action to be taken (Additional data to be collected, Who will collect it, By what date will the data be collected?) ______
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Intervention Design

/ Brainstormed possible Intervention Strategies:
List PROACTIVE strategies (e.g. What could you do in the environment to prevent the problem behavior from occurring? i.e. Provide teacher attention more frequently to avoid the child’s attention seeking behavior): ______
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List EDUCATIONAL strategies (e.g. Teaching a necessary skill or replacement behavior that results in the same outcome or function as the problem behavior): ____
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List FUNCTIONAL strategies (e.g. Replacement behavior that obtains the same function as the problem behavior and results in the problem behavior no longer leading to the same outcome): ______
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Select which proactive, educational and functional strategies to implement: ______

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/ Established intervention strategy tactics:
How will the intervention be implemented (list intervention steps and procedures)? _
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Who will implement the plan (e.g., teacher)? ______
When will the plan be implemented (e.g., start date, certain times during the day)? _
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Where will the plan be implemented (e.g., lunchroom, classroom, gym)? ______
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List how plan implementation and plan outcomes will be measured:
Plan Implementation / Outcomes for Student
/ How will it be monitored? (e.g. checklists)
Who will monitor? (e.g. school psychologist, principal, teacher)
When will it be monitored? (Time of day and duration)
Where will it be monitored? (Setting)

Progress Monitoring/Follow-Up

/ Plan for monitoring and follow-up:
Who is responsible for monitoring progress?______
How will intervention effectiveness be monitored (e.g., permanent products, observations)?______
Follow-up meeting date set to review progress?______