SST Worksheet #1: Student Support Team Request
Student’s Name:
School:
1.
Grade:
Birth Date:
Teacher:
Parent/Guardian:
Date:
Referred by:
Date parent notified of concern:
What is the major area of concern?
READING: 1.
Decoding Skills 2.
Oral Reading Fluency 3.
MATH: 1.
Computation 2.
Problem Solving 3.
Other:
BEHAVIOR:
Comprehension
4.
Other:
Comments:
2.
Core General Education Instruction (Tier I)
Student has participated in daily core instruction using research-based practices provided to the entire class by the classroom teacher.
Student has participated in small group, differentiated instruction by the classroom teacher as part of core instruction.
Other differentiation strategies/accommodations have been implemented:
Extended time
Word banks
Reward chart
Tasks assigned in chunks
Pre-teach vocabulary
Check-ins
Peer tutor
Mnemonics
Reward peers for desired behavior
Extra practice/repetition
Varied format test
Communication home
Lower readability
Visual cues
Motor breaks
Color-coded materials
Preferential seating
Warnings
Graphic organizer
Brain/body breaks
Timer
Study guides
Proximity
Positive reinforcement
Manipulatives
Choices
Arrange classroom environment
Steps listed
Re-direction
Self monitoring chart
Assignment options
Cues (verbal or visual)
Ignore the behaviors
Shortened assignments
Boundary identification
Take a break
Multisensory instruction
Shorten directions/requests
“If then” or “First, then” statements
Other differentiation strategies not listed above:
1
Updated 10.28.14
SST Worksheet #1: Student Support Team Request
3.
Indicate supports the student is currently receiving or has received in the past.
Early Intervention/Preschool
Title I:
Reading
Math
Special Education:
Reading
Math
Behavior
Speech
Other:
Read180
EL Services
504 Plan:
Reading Corps
Math Corps
RtI Intervention:
Tutoring
Retention – When:
Other:
4.
Do you have concerns in the following areas?
Attendance
Yes
No
Medical
Yes
No
Social/Emotional
Yes
No
Behavioral
Yes
No
Home Issues
Yes
No
Academic
Yes
No
Communication
Yes
No
Fine Motor Skills
Yes
No
Gross Motor Skills
Yes
No
Comments:
5.
Please obtain the following information from the school nurse and/or Skyward:
Vision Screening:
Pass
Fail
Number of days absent:
Hearing Screening:
Pass
Fail
Number of times tardy:
Comments:
2
Updated 10.28.14
SST Worksheet #1: Student Support Team Request
READING
6.
If decoding skills have been identified as an area of weakness:
Student’s phonemic awareness has been evaluated and, if warranted, targeted intervention has been provided.
Student has been provided with systematic, explicit phonics instruction.
Student has been provided with regular opportunities to practice learned decoding skills in texts.
Teacher has systematically collected progress monitoring data to determine the student’s response to the intervention provided.
Intervention/progress monitoring data are attached.
Other information:
7.
If a student’s oral reading fluency has been identified as an area of weakness:
Student’s phonics skills have been evaluated and, if warranted, targeted intervention has been provided.
Student has been provided with regular opportunities to practice reading a variety of text at his/her independent level (at least 96% word
accuracy and 90% comprehension).
Student has been provided with teacher-directed fluency intervention focused on improving oral reading fluency with connected text.
Teacher has systematically collected progress monitoring data to determine the student’s response to the intervention provided.
Intervention/progress monitoring data are attached.
Other information:
8.
If a student’s reading comprehension skills have been identified as an area of weakness beyond what can be accounted for by identified
decoding and/or reading fluency deficits:
Student’s vocabulary skills have been evaluated and, if warranted, targeted intervention has been provided, with application to reading
comprehension.
Student’s broad oral language skills (e.g., listening comprehension) have been evaluated and, if warranted, targeted intervention has been
provided.
Student has been provided with explicit comprehension interventions (e.g., additional instruction in research-based comprehension strategies
such as summarization and use of graphic organizers; additional building of background knowledge and/or knowledge of text structure) to
address his/her specific comprehension needs.
Teacher has systematically collected progress monitoring data to determine the student’s response to the intervention provided.
Intervention/progress monitoring data are attached.
Other information:
9.
Other:
3
Updated 10.28.14
SST Worksheet #1: Student Support Team Request
MATH
10. If computation skills have been identified as an area of weakness:
Student’s conceptual understanding of numbers has been evaluated and, if warranted, targeted intervention has been provided (e.g., additional,
more explicit instruction with use of visual representations such as pictures or manipulatives.
Student’s automatic recall of facts has been evaluated and, if warranted, targeted intervention has been provided.
Student has been provided with explicit teaching of algorithms for calculation linking procedures to a conceptual understanding (e.g., written
procedures for 2-digit subtraction with regrouping, long division).
Student has been provided with regular opportunities to practice learned computation skills in appropriate contexts, including cumulative review
of previously learned skills.
Teacher has systematically collected progress monitoring data to determine the student’s response to the intervention provided.
Intervention/progress monitoring data are attached.
Other information:
11. If problem-solving skills have been identified as an area of weakness beyond what can be accounted for by identified calculation deficits
and/or poor reading:
Student’s math-related vocabulary and other oral language skills have been evaluated and, if warranted, targeted intervention has been provided,
with application to math problem solving.
Student’s specific problem-solving skills (e.g., ability to determine which operation to use to solve a problem, identifying relevant vs. irrelevant
information) have been evaluated and, if warranted, targeted intervention has been provided.
Student has been provided with regular opportunities to practice learned problem-solving skills, including cumulative review of previously
learned skills.
Teacher has systematically collected progress monitoring data to determine the student’s response to the intervention provided.
Intervention/progress monitoring data are attached.
Other information:
12. Other:
BEHAVIOR
13.
If behavior issues have been identified as an area of weakness:
Targeted intervention has been implemented.
Teacher has systematically collected progress monitoring data to determine the student’s response to the intervention provided.
Intervention/progress monitoring data are attached.
Other information:
4
Updated 10.28.14