Instructions:
Indictors: For eachIndicator, select the most appropriateImplementation Status that reflects your school by putting an “X” under the appropriate column.
None – not in place or not begun yet
Little – started to implement or develop
Agree Some– progressing but not fully implemented
Strongly Agree– implementing fully
EPSS: Then indicate with a Y foryes, if your school’s EPSS contains specific and explicit language that addresses this indicator or N for no if your school’s EPSS does not.
Evidence:Please list the specific policies, practices, systems, structures, teams, tools, and/or strategies that your school is implementing that address the indicator. Please be as specific as possible.
Action Plan Log: As your teamprogressesthrough each section of this self-assessment, indicate in the appropriate Action Plan Log the next steps needed for progress in this area. This will assist you in settingpriorities and identifying the what, who and when needed tomove your work forward.
Each action itemcan have one or moreLeader. Youmayalsoidentifya person under Needs Attention From, who you need input or support fromto move forward.
There is alsospace to indicate the due date and a place to indicate when thatActionItem has been completed with an X. As you complete Action Items, please do not delete themas they are a record of your progress andaccomplishments.
System Level AssessmentProtocols(Structures, Data and Decision Rules)
Indicator / Implementation Status / EPSS / Evidence
None / Little / Agree Some / StronglyAgree / Y/N
1a. Atthebeginningoftheyearandperiodicallythereafter,areliableand validuniversalscreeningsystemforassessingallstudentsisinplaceformath.
1b. Atthebeginningoftheyearandperiodicallythereafter,areliableand validuniversalscreeningsystemforassessingallstudentsisinplacefor literacy.
1c. Atthebeginningoftheyearandperiodicallythereafter,areliableand validuniversalscreeningsystemforassessingallstudentsisinplacefor behavior.
1d. Adatamanagementsystemthatallowsfordevelopmentofdatachartsthat areeasytoreadandanalyzeisinplace.
1e.Cleardecisionrulesareusedtodetermineifsufficiencyofstudent progressateachTierandplacementforadditionalinterventionsasnecessary.
1f. Data(e.g.,Curriculum-BasedMeasurement,DIBELS,OfficeDiscipline Referrals)areusedtoidentifyat-riskstudentsinneedofsupplementaland/or intensiveinterventions.
1g. Resources(i.e.,people,time,andfunds)areallocatedtosupport implementationofinterventionsacrossmultipletiers.
1h.Coachingisavailabletosupportlearningskillsandimplementing interventions.
1i. AProblem-SolvingTeam(SAT,PLC,GoalTeam)meetsroutinelyto analyzeindividualstudentdataaggregatedby interventiontodeterminehow welleachinterventionis working.
1j. Progressmonitoringdataareusedtodeterminethedegreetowhicha student'srateofprogresshasimproved.
1k. Progressmonitoringdata(e.g.,Curriculum-BasedMeasurement,DIBELS, behavioralobservations)areusedto monitorthestudentperformancewho receivedTier2orTier3interventions.
1L. Familiesareroutinelyprovidedinformationontheresultsofscreeningand progressmonitoringfortheirstudent(s).
1m. Familiesareroutinelyprovidedinformationoninterventionsand strategiesusedtoincreaseperformancefortheirstudent(s).
1n .Aprocessisinplacefortwo-waycommunicationwithfamiliesaboutthe RtIprocessandhowtheycanbeengaged.
ActionItemforProtocols / Leader / Needsattentionfrom / DueDate / Completed
ProgramsandPractices:Literacy
Indicator / Implementation Status / EPSS / Evidence
None / Little / Agree Some / Strongly Agree / Y/N
2a. Grade level skills and concepts are commonly understood and are the focus of instruction ofteachers and administrators for Reading.
2b. Students receive high quality, research-based instruction in the general education setting and addresses the five components of reading: phonemic awareness, decoding/phonics/word recognition; fluency; vocabulary; comprehension in Reading.
2c. Classroom teachers, special education teachers, specialists, and other related-services personnel collaborate to effectively implement high quality, research-based instruction/curricula in general education for Reading.
2d. Programs and materials are implemented with a high level of fidelity for Reading.
2e. Internal audits, or “fidelity checks” are used to gauge the implementation of our programs for Reading (walk-through).
2f. Decision rules (e.g., entering, continuingin,andexiting)about placement in Tier 2 and Tier 3 are specified.
ProgramsandPractices:Literacy
Indicator / Implementation Status / EPSS / Evidence
None / Little / Agree Some / Strongly Agree / Y/N
2g. Tier 2 interventions ensure that any supplemental and/or intensive interventions are alignedwith core instruction in the general education classroom.
2h. Tier 3 Interventions are designed to target student's needs and specify the frequency, intensity, andduration needed for effectiveness.
ActionItemforProtocols / Leader / Needsattentionfrom / DueDate / Completed
Programs and Practices: Math
Indicator / Implementation Status / EPSS / Evidence
None / Little / Agree Some / Strongly Agree / Y/N
3a. Math instruction addresses 4 essential domains: problem-solving; arithmetic skill/fluency; conceptual knowledge/number sense; reasoningability.
3b. Students receive high quality, research-based math instruction byqualified staff in the general education setting.
3c. Classroom teachers, special education teachers, math specialists,and other related-services personnel collaborate to effectively implement high quality, research-based math instruction/curricula in general education under the overall direction of the general education teacher.
3d. Internal audits, or “fidelity checks” are used to gauge the implementation of our math programs (walk-through).
3e. Math goals and objectives are commonly understood andconsistently used by teachers andadministrators within and across grades.
Programs and Practices: Math
Indicator / Implementation Status / EPSS / Evidence
None / Little / Agree Some / Strongly Agree / Y/N
3f. Decision rules (e.g., entering, continuingin,andexiting)aboutplacement in Tier 2 and Tier 3 are specified.
3g. Tier 2 interventions ensure that any supplemental and/or intensiveinterventions are alignedwith core instruction in the general education classroom.
3h. Tier 3 Interventions are designed to target student's needs and specify the frequency, intensity, andduration needed for effectiveness.
ActionItemforProtocols / Leader / Needsattentionfrom / DueDate / Completed
Programs and Practices: Behavior
Indicator / Implementation Status / EPSS / Evidence
None / Little / Agree Some / Strongly Agree / Y/N
4a. Expected student behaviors are established for non-classroomsettings.
4b. Expected student behaviors are established for the classroom.
4c. A small number (e.g., 3-5) of positively & clearly stated studentexpectations or rules are defined.
4d. Expected student behaviors are taught directly.
4e. Expected student behaviors are reinforced regularly.
4f. Expected student behaviors are acknowledged.
Programs and Practices: Behavior
Indicator / Implementation Status / EPSS / Evidence
None / Little / Agree Some / Strongly Agree / Y/N
4g. The difference between major problembehaviors and minorproblembehaviors are clearlyidentified and understood.
4h. The staff agrees on which behaviors are to be addressed in theclassroomand which behaviors are to be addressed by an administrator.
4i. A variety of appropriate responses/consequences to minor (non- office-managed) problem behaviors have been identified.
4j. A variety of appropriate responses/consequences to major (office-managed) problembehaviors have been identified.
ActionItemforProtocols / Leader / Needsattentionfrom / DueDate / Completed
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