Note: Interventionist refers to the individual(s) delivering the intervention. Student: DOB: Grade: 1. Describe the area being targeted for intervention and means of identifying the need. 2. Indicate the area(s) of suspected disability (interventions must match deficit areas of the disability suspected) : 3. Describe the Tier I intervention(s) implemented in the general education classroom to address the area being targeted and the name of the interventionist. Dates Frequency of Service Amount of Time Impact (What was the end result? What was the level/score?) Expected Progress (Where should the student have been at the end of this intervention?) Begin End 4. Describe the Tier II intervention which was implemented to address the area being targeted and name of the interventionist. Dates Frequency of Service Amount of Time Impact Expected Progress (Where should the student have been at Begin End
(What was the end result? What was the final level/score?) the end of this intervention?) 5. Describe the Tier III intervention which was implemented to address the area being targeted and name of the interventionist. Dates Frequency of Service Amount of Time Impact (What was the end result? What was the final level/score?) Expected Progress (Where should the student have been at the end of this intervention?) End 6. Concerns with fidelity of implementation were observed in the following areas (yes or no): Tier I (Core Instruction)? Tier II? Tier III? If “yes” to any areas, please explain: 7. Describe the parental involvement in the data sharing and decision making process:
Age Appropriate Has difficulty modulating voice (e.g. too soft, too loud) Has trouble naming people or objects Has difficulty staying on topic Inserts invented into conversation Has difficulty re-telling what has just been said Demonstrates slow and halting speech, using lots of fillers (e.g., uh, um, and you know) Mispronounces words frequently Has difficulty rhyming Has limited interest in or stories Has difficulty understanding instructions or directions Reading (Basic Reading Skills, Reading Comprehension, Reading Fluency Skills) Age Appropriate Confuses similar-looking letters and numbers Demonstrates poor memory for printed words Has trouble naming letters Has poor retention of new vocabulary Dislikes and avoids reading or reads reluctantly Has problems associating letters and sounds, understanding the difference between sounds in words or blending sounds into words Written Language (Written Expression) Age Appropriate Has difficulty remembering shapes of letters and numerals Dislikes and avoids writing and copying Frequently reverses letters, numbers and symbols ______________________________________________________________________________ ______________________________________________________________________________
Does not pick up on other people’s mood/feelings (e.g., may say the wrong things at wrong time) May not detect or respond appropriately to teasing Has difficulty ‘joining in’ and maintaining positive social status in a peer group Has trouble knowing how to share/express feelings Has trouble ‘getting to the point’ (e.g., gets bogged down in details in conversation) Has difficulty with self-control when frustrated Has difficulty dealing with group pressure, embarrassment and unexpected challenges Attention (All Areas) Age Appropriate Has difficulty sustaining attention in work tasks or play activities Has difficulty organizing tasks and activities Loses things consistently that are necessary for tasks/activities (e.g., toys, school assignments, pencils, books, or tools) Is easily distracted by outside influences Is forgetful in daily/routine activities Gross and Fine Motor Skills (All Areas) Age Appropriate Appears awkward and clumsy, dropping, spilling, or knocking things over Has limited success with games and activities that demand eye-hand coordination (e.g., piano lessons, basketball, baseball) Has trouble with buttons, hooks, snaps, zippers and trouble learning to tie shoes Creates art work that is immature for age Demonstrates poor ability to or write ‘within the lines’ Grasps pencil awkwardly, resulting in poor handwriting Experiences difficulty using small objects or items that demand precision (e.g., Legos, puzzle pieces, tweezers, scissors)
Written Language (Written Expression) Age Appropriate Writing is messy and incomplete, with many cross-outs and erasures Uses uneven spacing between letters and words, and has trouble staying ‘on the line’ Copies inaccurately (e.g., confuses similar-looking letters and numbers) Spells poorly and inconsistently (e.g., the same word appears differently other places in the same document) Has difficulty proofreading and work to develop ideas in writing so written work is incomplete and too brief Math (Math Calculation, Math Problem Solving) Age Appropriate Has difficulty learning strategic counting principles (e.g., by 2, 5, 10, 100) Poorly aligns numbers resulting in computation errors Has difficulty estimating quantity (e.g., quantity, value)Has difficulty with comparisons (e.g., less than, greater than) Has trouble telling time Has trouble conceptualizing the passage of time Has difficulty counting rapidly or making calculations Has trouble interpreting graphs and chart Social Emotional (All Areas) Age Appropriate Does not pick up on other people’s mood/feelings (e.g., may say the wrong things at the wrong time) May not detect or respond appropriately to teasing Has difficulty ‘joining in’ and maintaining positive social status in a peer group Has trouble knowing how to feelings
Has trouble ‘getting to the point’ (e.g., gets bogged down in details in conversation) Has difficulty dealing with group pressure, embarrassment and unexpected challenges Attention (All Areas) Age Appropriate Fails to pay close attention to details or makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention in work or play activities Has difficulty organizing tasks and activities Loses things consistently that are necessary for tasks/activities (e.g., toys, school assignments, pencils, books, or tools) Is easily distracted by outside influences Is forgetful in daily/routine activities Gross and Fine Motor Skills (All Areas) Age Appropriate Has limited success with games and activities that demand eye-hand coordination (e.g., piano lessons, basketball, baseball) Grasps pencil awkwardly, resulting in poor handwriting Dislikes and avoids writing and drawing tasks Other Notes or Observed Behavior
___ Reading Fluency Skills ___ Listening Comprehension ___ Mathematics Problem Solving ___ Mathematics Calculation Language (Oral Expression, Listening Comprehension, Other:__________________________ ) Age Appropriate Has difficulty modulating voice (e.g., too soft, too loud) Uses imprecise language and has a limited vocabulary Demonstrates slow and halting speech, using lots of fillers (e.g., uh, um, and, you know) Uses poor grammar or misuses in conversation Confuses words with others that sound similar Inserts malapropisms (‘slips of the tongue’) into conversation (e.g., a rolling stone gathers no moths; he was a man of great statue) Has difficulty understanding instructions or directions Has difficulty with pragmatic skills (e.g., understands the relationship between speaker and listener, stays on topic, gauges the listener’s degree of knowledge, makes inferences based on a speaker’s verbal and cues) Reading (Basic Reading Skills, Reading Comprehension, Reading Fluency Skills) Age Appropriate Frequently loses place while reading Confuses similar-looking words (e.g., beard, bread) Demonstrates poor memory for printed words Has weak comprehension of ideas and themes Reads slowly Guesses at unfamiliar words rather than using word analysis skills Substitutes or leaves out words while reading Dislikes and avoids reading or reluctantly Written Language (Written Expression) Age Appropriate Writing is messy and incomplete, with many cross-outs and erasures
Is slow to learn new games and master puzzles Has difficulty listening and taking notes at the same time Has difficulty generalizing (applying) skills from one situation to another Behavioral Observation Checklist for Behavioral Concerns Student: Grade: Name: Date: Observer Name/Title: Time: Target behavior of concern identified in ARC evaluation plan: _________________________________ Physical environment: (Check all that apply and note the amount of time spent in each location) At desk At listening center At learning center At table Seated on floor with group At chalkboard Playground Cafeteria Gym Other:__________ Task (defined by teacher) for the student to perform:______________________________________ Observation Method to be Used: Method 1: Interval Recording of Targeted Behavior or Academic Engaged Time (on-task) Method 2: Frequency/Duration of Targeted Behavior Method 3: Anecdotal Observation Method 1: Interval Recording of Targeted Behavior or Academic Engaged Time (on-task) __________________________________________________________________