SAT Referral Packet - DOC by HC121003181329


									                             Trigg County Public Schools
              Targeted Assistance & Growth Team Referral Information

Student                                                               Grade                Date
School                                                    Teacher
Name of Referring Teacher
Parent/Guardian                        Address

A.      Mark only areas of concern below that significantly affect the student’s classroom experiences. Rate your
        concern as (H) High or (S) Some. If you are not sure, do not mark the item.
                  Academic/Cognitive                                         Social Competence
______Basic Reading                                       ______Interaction with peers
______Reading Comprehension                               ______Interaction with adults
______Vocabulary                                          ______Acceptance of rules
______Basic Math                                          ______Acceptance of correction
______Math Reasoning                                      ______Acceptance of failure
______Written Expression                                  ______Mood Swings
______Completion of work                                  ______Repetitive behaviors
______Concentration                                       ______Self-concept
______Time on task                                        ______Inactivity or withdrawal
______Following directions                                ______Cooperation
______Problem solving                                     ______Disruptive
______Attention span                                      ______Other
______Memory skills
______Organizational skills
                    Communication                                                   Physical
______Communicating basic needs and wants                 ______Gross motor skills
______Articulation                                        ______Fine motor skills
______Voice quality                                       ______Vision
______Written expression                                  ______Hearing
______Receptive language                                  ______Activity level
______Expressive language                                 ______General medical/ health
______Fluency                                             ______Developmental milestones
______Public speaking                                     ______Self-help skills
______Knowledge of sound/letter association               ______Other (specify)____________________________
______Language fluency

B.       Archival Record Review (To be completed by Guidance Counselor)
         Add any other information you can to help the team better understand your concerns.
         1. Describe the student’s strengths, interests, preferences:

         2.    Has the student been retained?        No             Yes, Explain
         3.    Are there any significant health      No             Yes, Explain

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         4.   Is the student taking                  No             Yes, Explain

        5. Screening
        Type of Screening                       Most Current Date                  Status (Pass, Fail, Refer, etc.)
Speech Language

         6. Attendance (may attach attendance report)
Grade or Year
Days Present

        7. Please check and attach the following information if applicable.
     DIBELS                               Report card/Progress Reports                Discipline record
     GMADE                                ThinkLink                                   Parent Contact
     GRADE                                Work samples                                Other -
     CTBS                                 Evaluation/assessments                      Other -

    C. Prior Actions Taken to Address the Concern
            a. Check any diverse learning strategies that have been used prior to this point to address the
                 concern. Provide evidence (if applicable including assignments and/or scoring guides.)

          Academic Strategies                        Behavioral Strategies                    Programatic Supports
     Using tape recorder                         Incorporating cultural                  Outside agency involvement,
                                                 differences                             i.e. residential treatment,
                                                                                         Impact, mental health, etc.
     Previewing; rephrasing                      Discussion with student                 ESL (English as a Second
     Using graphic organizers                    Change in schedule or order             Speech/Language Therapy
                                                 of activities                           Occupational Therapy
                                                                                         Physical Therapy
     Contracts                                   Consistency of enforcement              Title I reading
     Peer tutoring                               Denied desired                          Counseling
     Use modified curricular materials           Notes/phone calls to parents            ESS
     Reinforcement schedules                     Loss of privileges                      Medical
     Acknowledging correct responses             Modified BIP- Behavior
                                                 Intervention Plan
     Dividing task into smaller portions         Offer strategies for self-
     (chunking)                                  management
     Providing bilingual signs/labels            Observation by another staff
     Using music, art, drama                     Giving opportunities for
     Change in curriculum pacing                 Giving opportunities for

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    Memory drills (math facts)                   Promoting family involvement
    Memory drills (sight words)                  Building on student’s
    Pattern books and word families              Offered options/choices
    Manipulatives for math, other                Reprimands
    Accessing prior knowledge                    Ignored the behavior
    Provide extra assistance                     Shaping

       b.        If interventions have been tried, describe their effectiveness. Submit progress data, if available.

       (Optional) If they were ineffective, what do you hypothesize as the possible reason?

Comments: List any information that would be beneficial to the TAG team.

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