PLT Data Collection Tool-Underwood Elem.

Student Name______Teacher ______Grade ______

Parent Name______Phone ______Email______

Parent Contact 1stContact ______2nd Contact ______

Step 1: Identify areas of concern. Concern based on assessment data and work samples.

Student’s Present Level (baseline) / Student’s Expected Level / Check the Area of Primary Concern
Reading
Math
Writing
Behavior
Attach a copy of Individual Student Reading Profile, Individual Student Math Profile, Individual Student Writing Profile, Behavior, including SWIS data and any other related information.
Based on diagnostic assessments, identify the area of concern. Use dates.
Reading / Writing
Letter and Sound Identification / Composing
Concepts of Print / Content Features
Phonological Awareness /
  • Focus

Decoding (phonics) /
  • Organization

High Frequency Words /
  • Support and Elaboration

Fluency /
  • Style

Comprehension / Conventions
  • Sentence Structure

Language /
  • Usage

Expressing ideas
Understanding directions /
  • Spelling
  • Punctuation
  • Capitalization

Self-regulation
Math / Behavior
Goal 1: Number and Operations / Focus/Attention
-Magnitude and Quantity / Work Completion
-Numeration and Base Ten
-Different Forms of a Number
Goal 2: Measurement / Conduct
Goal 3: Geometry / Attendance/Tardy record (# of occurrences)
Goal 4: Data Analysis
Goal 5: Algebra

Results of Vision and Hearing Screening

Vision:Far ___/___/___ Near ___/___/___ Hearing:___/___/___

Pass/Fail Pass/Fail Pass/Fail

Step 2: Select Intervention Focus: Prioritize concerns. Choose one concern and brainstorm strategic interventions.

Step 3: Write a positive objective for chosen concern. Choose tworesearch-based interventions Think about and record who will implement the intervention, how much (intensity), how often (frequency), and for how long (duration).

Objective #1: PLT Date : ______
Researched-Based Intervention/Strategy / Who? To What Extent? How often? How long?
Who will implement?
How often?
How much time? / Effectiveness of Intervention/Strategy
Effective / In-consistent / Not Effective
Intervention 1
Intervention Adjustment
Progress Monitoring of Intervention 1
Name of monitoring tool:
Academic / Baseline / Week 1 / Week 2 / Week 3 * / Week 4 / Week 5 / Week 6 / GOAL
Dates
Results
*Between Weeks 3 & 4 evaluate data. Is student making progress? Or is an adjustment warranted?

At the end of 6 weeks of monitoring 2 research based interventions, evaluate effectiveness and decide as PLT whether SST referral is warranted.

Objective #1- PLT Date:______
Researched-Based Intervention/Strategy / Who? To What Extent? How often? How long?
Who will implement?
How often?
How much time? / Effectiveness of Intervention/Strategy
Effective / In-consistent / Not Effective
Intervention 2
Intervention Adjustment
Progress Monitoring of Intervention 1
Name of monitoring tool:
Academic / Baseline / Week 1 / Week 2 / Week 3 * / Week 4 / Week 5 / Week 6 / GOAL
Dates
Results
*Between Weeks 3 & 4 evaluate data. Is student making progress? Is SST referral warranted?

At the end of 6 weeks of monitoring 2 research based interventions, evaluate effectiveness and decide as PLT whether SST referral is warranted.