STUDENT INTERVENTION PROCESS (SIP) REFERRAL and INTERVENTION MONITORING FORM

Student Name:

D.O.B. Age: Grade: Sex:

Classroom Teacher:

Parents:

Address:

Phone Number:

The Student Intervention Process (SIP) Team may consist of the principal, school counselor, school psychologist, special education teacher(s), Title I and grade level representatives. You may consult with any of these people throughout this process. The SIP Team will be available to meet twice per month. All SIP referrals need to be submitted by the last Thursday of April in any given school year.

Step I. Student Background Information

A.  Fill out Teacher Concern Checklist/Behavioral Concern Checklist (prioritize concerns)

B.  List your attempts to gather information about the student on the “What have you tried?” form

Step II. Parent/Student and Other Consultations

A.  Discuss concerns with the parent/student/others. Document on the “What have you tried?” form.

B.  Ask former teachers, fellow teachers, specialist teachers, and playground supervisors about student. Document on “What have you tried” form.

C.  Identify any other activities that have been attempted on behalf of the child.

------Intervention

Step III. Revisit Teacher Concern Checklist/Behavioral Concerns Checklist

A.  Begin a Targeted Intervention based on the skill(s) of concern. Document on the “Intervention Planner.”

B.  If the students is serviced by Title I, documentation will be on the Individual Learning Plan for Title I.

Step IV. Intensive Interventions and Progress Monitoring

  1. Meet to discuss student progress with SIP Team. Be sure that each area of concern is targeted with an appropriate intervention. The intervention(s) must be documented, and data collection/progress monitoring must occur at least weekly using probes. Progress toward the specific goal will be discussed at that meeting.
  2. Discuss student progress with Intervention (RtI) Team (bring progress monitoring data, work samples etc. to meeting) to gather additional strategies such as implementing another intervention or consider a referral for special education. Note: At least (2) scientifically-based or evidence-based interventions must be completed in each area of concern with weekly progress monitoring data prior to an IEP team being able to make an eligibility determination at Tier 3.

Teacher Concern Checklist
Student Name / Teacher/Team
Date Completed / Grade
Review the areas below. Please place a checkmark in the box next to each area of concern for the student within your classroom. Color in each box if an area is considered a strength.
Health / Vision / Hearing
Other / Other
Reading / Phonological Awareness / Phonics
Vocabulary / Decoding
Comprehension
Literal Inferential / Fluency
Other
Mathematics / Number Sense / Algebra
1:1 Correspondence / Geometry
Number Identification / Fractions
Counting from / Decimals
Order / Estimation
Basic Facts &
Computation / Money
Addition / Measurement
Subtraction / Time
Multiplication / Word Problems
Division / Other
Written Expression / Spelling / Legibility (Handwriting)
Punctuation / Spacing
Sentence Construction / Capitalization
Paragraph Formation / Written Content
Written Product Length / Other
Content / Science / Social Studies
Work Completion / Writing Down Assignments / Taking Correct Materials Home
Doing Assignment at Home / Doing Assignments in Class
Communication / Articulation / Verbal Expression
Fluency / Limited English Proficiency
Language Comprehension / Voice
Social Language (Pragmatics) / Other
Motor Skills / Fine Motor / Visual Motor Coordination
Gross Motor / Other
Related Areas / Self-Help Skills / Study Skills
Test-Taking Skills / Organizational Skills
Independent Work Skills / Other
For behavioral concerns, please see the back.

Teacher Comments:

Behavioral Concern Checklist

Check each behavior that is a concern for this student.
Passively Off-Task
(Short Attention Span) / Physical Aggression Toward Adults
Impulsive Acting Out / Physical Aggression Toward Peers
Excessive Activity Level / Stealing
Withdrawn Behavior / Poor Work Independence
Poor Peer Relationships / Poor Work Completion
Poor Adult Relationships / Destruction of Property
Making Noises During Class / Constant Complaining/Whining
Calling Out During Class / Lying
Talking with Peers During Class / Excessive Questions During Class
Disrespectful/Inappropriate Language / Arguing
Out of Seat / Temper Tantrums
Noncompliance with Requests / Hiding in the Classroom
Crying / Running Away from Adults
Poor Personal Hygiene / Negative Self-Statements
Playing with Objects During Instruction / Careless Work Completion
Teasing Peers / Invading Other’s Physical Space
Organization / Threatening Others
Work Refusal / Work Avoidance
Other (Explain) / Other (Explain)

Review the boxes you checked (front page & above). Prioritize your top 3-5 concerns (1 = most important). When prioritizing, try to give preference to skills/concerns that if improved would improve other skills/concerns.

Prioritized Concerns

1.

2.

3.

*Rate the severity of concern 1 above.

Mild Severity Mild-Moderate Moderate Severity Somewhat Severe Very Severe

What Have You Tried?

Student: Teacher:

What Have You Tried?
(i.e. Reviewed file, contacted parent, helped student with organization, breaks etc.) / When Did you Try this?
(Date Range) / Result: How did it go?

Student Name

Classroom Teacher

Intervention Description / Intervention Delivery / Check-Up Date / Assessment Data
Describe each intervention that you plan to use to address the student’s concern(s).
(e.g. MVRC, Fast ForWord, IM, READ 180, Reflex Math, Academy of Math) Behavior (Self-Monitoring, Positive Behavioral Interventions, Praise, Encouragement, Reinforcement etc.) / Intervention Implemented for each area of concern:
·  Target area(s) clearly identified
·  List key details about delivery of the intervention, such as: (1) where & when the intervention will be used; (2) the adult-to-student ratio; (3) how frequently the intervention will take place; (4) the length of time each session of the intervention will last—Refer to Fidelity requirements
(e.g.) Reading: Phonemic Awareness / Select a date when the data will be reviewed to evaluate the intervention. / Note what classroom data or progress monitoring tool(s) will be used to establish baseline, set a goal for improvement, and track the student’s progress during this intervention.
Type(s) of Data to Be Used:
Baseline / Goal / Result
Type(s) of Data to Be Used:
Baseline / Goal / Result
. / Type(s) of Data to Be Used:
Baseline / Goal / Result
. / Type(s) of Data to Be Used:
Baseline / Goal / Result