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									                                                    LCMT Meeting Checklist

Date of Meeting: ____________ Time: ___________ Name of Student:____________________________________

Please complete this form for each student of concern and bring it and the following items with you to your LCMT appointment.
If you need to cancel your appointment, please give 24 hours notice.

Historical Information
           Print all documents that appear when you select the LCMT Button in Encore and bring with you to the LCMT
           appointment.
           Bring the student's CUM file                                       Pertinent medical information if available
           Survey Level and Diagnostic Assessments if available               Vision and Hearing screening results
           % of class on benchmark on DIBELS                                  Log of anecdotal record of parent contact



Current Intervention
If an intervention has been tried, please describe it below.

Intervention: _______________________________________________________________________________________
___________________________________________________________________________________________________
Who applies the intervention? ________________________________________________________________________
When is the intervention applied? _____________________________________________________________________
How often is the intervention applied? _________________________________________________________________
Where is the intervention applied? ____________________________________________________________________
What have been the results of this intervention? ________________________________________________________



                                                    LCMT Meeting Checklist

Date of Meeting: ____________ Time: ___________ Name of Student:____________________________________

Please complete this form for each student of concern and bring it and the following items with you to your LCMT appointment.
If you need to cancel your appointment, please give 24 hours notice.

Historical Information
           Print all documents that appear when you select the LCMT Button in Encore and bring with you to the LCMT
           appointment.
           Bring the student's CUM file                                       Pertinent medical information if available
           Survey Level and Diagnostic Assessments if available               Vision and Hearing screening results
           % of class on benchmark on DIBELS                                  Log of anecdotal record of parent contact



Current Intervention
If an intervention has been tried, please describe it below.

Intervention: _______________________________________________________________________________________
___________________________________________________________________________________________________
Who applies the intervention? ________________________________________________________________________
When is the intervention applied? _____________________________________________________________________
How often is the intervention applied? _________________________________________________________________
Where is the intervention applied? ____________________________________________________________________
What have been the results of this intervention? ________________________________________________________

								
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