Intervention Specialist Forms: Aldine Independent School District Safe and Secure Schools

Aldine Independent School District
Safe and Secure Schools

Intervention Specialist Forms

Forms for an Intervention Specialist to use in documenting prevention and intervention services.
Forms included are:

Behavior Observation Sheet-front & back
The primary form used by the Intervention Specialist for teacher and assistant principal
referrals and screening. This form should be readily available to any staff needing to
refer a student.
Intervention Specialist Referral Log
This log is for Intervention Specialists and is often placed within your Intervention
Specialist Binder. This allows for an accurate listing of students referred for services.
Follow up Observation Sheet
This is for classroom teachers to complete after the initial referral. It is how we
determine if the behavior has changed in the classroom.
Student Referral Sheet
This form is available for students to self-refer. Sometimes it is easier to check a list
rather than disclose verbally.
Intervention Specialist Checklist
There are certain duties that may need to be completed to provide services to students.
This checklist helps to keep things from falling through the cracks.
Intervention Specialist Feedback Form
This is how the Intervention Specialist communicates back to the student's teachers. This
form lets the teachers know what is planned for the student.
Process Evaluation
This form is used in evaluating the Intervention Specialist services, including how well
the services are being used, and what resources are being tapped for the students.
Intervention Specialist Referral Tracking Record
This form is used to track individuals who have been referred to the Intervention
Specialist, particularly in those areas that are measurable, such as grades, attendance, and
behavior.
Campus Impact
This is a way to contrast certain measurable outcomes at school, pre and post-
intervention services. This can answer the question, has the Intervention Specialists
services made an impact on our overall school?
Staff Satisfaction Survey
To gain some idea of what the staff thinks about the Intervention Specialist, use this
survey.
Student Satisfaction Survey
To gain some idea of what the students think about the Intervention Specialist, use this
survey. Be mindful that this survey is helpful when students know that they have been
referred to the Intervention Specialist and have been screened/received services. Many
students have no idea that they have been identified and screened.
Intervention Specialist Team Action Planning Sheet
This form is used to create a plan of action, outline implementation strategies, identify
staff needed, identify resources needed, and project a completion date.

Behavior Observation Sheet
Confidential

STUDENT: _____________________ M / F GRADE/AGE:_____/____ DATE:

COMPLETED BY: SUBJECT: PERIOD(s):

Please check the patterns of behaviors

you have observed and forward this to
no later than
STUDENT'S STRENGTHS
___Self motivated/self starter
___Engaged in school/class
___Displays sense of humor
___Has creative outlet(s)
___Asks for assistance
___Shows integrity
___Stands up to peer pressure
___Responsible for self
___Thinks before acting
___Sound decision-making skills
___Empathetic or sensitive
___Respects cultural differences
___Resolves conflicts peacefully
___Tolerates change
___High self-esteem
___Positive view of future

INTERESTS:

COMMUNICATION
Have you communicated with the
students parents?
___Yes,
___Phone; date(s)________
___Conference; date(s)____
___No
(Write comments on back)

Students current grade in your
class? _
Students last report card grade in
your class?
Number of absences in your
class?
Number of times youve referred
the student for discipline
violations?

Use the back to document any
intervention or accommodations
that have been tried with this
student, including frequency &
duration, and whether or not they
were helpful.

BEHAVIORS
___Inattentive
___Easily distracted
___Forgetful
___Disorganized
___Defiance of rules
___Irresponsible
___Blaming
___Fighting/argumentative
___Secretive behavior
___Cheating
___Dramatic attention-getting

___Verbal abuse
___Obscene language/gestures
___Crying inappropriately
___Physically aggressive
___Bullying others
___Impulsive
___Stealing
___Vandalism
___Rigid obedience
___Extremely negative

___Hyperactive or nervous
___Agitation/fidgety
___Excessive demands on
teacher
___Day dreams regularly
___Unresponsive to interaction
___Easily led by others
___Sudden change in peers
___Refuses to comply with
requests
___Isolating/withdrawn
___Apathetic

___Expression does not match
feelings
___Excessive sadness
___Expresses self-destructive
thoughts/actions
___Dishonesty
___Excessive mood swings

___Expresses fear for self or
others
___Less/more mature than peers
___Expresses low self-esteem
___Erratic behavior changes
___Violates others boundaries
___Sexually preoccupied
ACADEMIC
___Low grades
___Drop in grades
___Academic failure
___Inconsistent daily work
___Does not follow directions
___Lack of motivation
___Change in student to teacher
relationship
___Change in participation
___Overly sensitive to criticism
___Compulsive over-achiever
___Easily frustrated/gives up
___Homework incomplete
___Lacking English skills

CLASS ATTENDANCE
___Excessive absenteeism
___Patterns of absences
___Frequent tardiness
___In jeopardy of losing credit
___Frequent visits to restroom
___Frequent visits to nurse
___Frequent visits to counselor

EXTRACURRICULAR
ACTIVITIES
___Loss of interest
___Increased non involvement
___Loss of eligibility
___Dropped out of activity
___Over extended in activities
___Unable to meet deadlines

PHYSICAL CONCERNS
___ Frequently fatigued
___ Sleeping in class
___ Impaired coordination
___Difficulty with vision/hearing
___ Poor hygiene
___ Rapid increase/drop in
weight
___ Frequent physical
complaints
___ Frequent illnesses
___ Burn marks/bruises/cuts
___ Slurred speech
___ Smells of tobacco/marijuana
___ Smells of alcohol
___ Runny nose
___ Red or glassy eyes


Teacher Observation Comments
(back of Behavior Observation Sheet)

Student: Date:

Is this referral in any way related to the childs ability to speak, read, or write English?
___yes ___no

What is the student not able to do that you want himor her to do? Be as specific as you can!

What is the student doing that you do not want himor her to do? Be as specific as you can!

What interventions or accommodations have been implemented consistently with this student. Include
description for each intervention along with frequency, duration and outcome.

Describe intervention:

1.

Date intervention started: Date intervention ended: Effective?

2.


3.


Comments/Students Interests:


Staff completing this form
Intervention Specialist Referral Log
:

Campus: School Year:

Intervention Specialist:

Student Referred
(name or ID #)
Date
Referred
Date
Reviewed
Grade
Level

Gender

Ethnicity
Plan code
Completion
Date
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

1 Support Group 8 Special Education 15 PAL
2 Individual Counseling 9 Outside Assessment 16 ESL
3 Mentor 10 Parent Conference 17 - Tutorials
4 Classroom Modification 11 Extra-Curricular Activities 18 Community
5 Conflict Resolution 12 Behavior Contract 19 No Action
6 Referral to the nurse 13 Referral for speech/hearing 20 -- Referred last year
7 Alternative Education 14 504 Committee 21 Student Organization
22 - Other


Follow Up Observation Sheet

In an attempt to see if the student has benefited fromthe Intervention Specialist services, we are asking for you to
complete the section below. Your feedback is essential and is appreciated.

Student: Grade: Period: Age:
Date of initial referral: Todays date:
Observer: Position:
Grade on last report card: Current grade in your class:

Academic Quite Often Sometimes Rarely Never
Participates in class
Completes assignments on time
Asks for help
Offers assistance to others
Is self-motivated
Has realistically high expectations
Works up to ability
Is organized
Classroom Behavior Quite Often Sometimes Rarely Never
Follows classroomrules
Sits in seat
Peaceful with other students
Interacts well with others
Respects boundaries
Respects school property
Cooperates with others
Obeys rules and requests
Assertive
Spends time alone
Is honest with others
Social Interactions Quite Often Sometimes Rarely Never
Responds to interaction
Has friendships in class
Interacts with other students
Appears happy and content
Shows patience with others
Has strong mood swings in class
Acts age appropriate
Demonstrates sense of humor
Is empathetic towards others
Stands up to peer pressure
Expresses feelings appropriately
Makes good decisions in class
Tolerates change in class

Comments:


Student Referral Sheet
Name:_____________________________ Grade: ___________ Date:____________
Concerns in my life: Often Sometimes Rarely Never
My grades are low
I dont get along with my teachers
I get in trouble in school
I have no friends or a few friends
I fight with my friends
I am picked on
I dont fit in
I want to hurt someone
I want to hurt myself
I get in trouble at home
There are problems at home
I drink alcohol
I use other drugs
I smoke cigarettes
I make poor decisions
I feel sad
I feel angry
I feel nervous
I feel scared
Other:
Good things in my life:
Often Sometimes Rarely Never
I have friends
I handle peer pressure well
I feel like I fit in
I get good grades
I complete my assigned schoolwork
I pay attention in class
I get along with my teachers
I get along with my family
I ask for help when I need it
I have talents and abilities
Other:

Things I want to accomplish (check all that apply):
I want to get along better with my teachers
I want to improve my grades
I want to be involved in extra curricular activities
I want to have more friends
I want to get along better with my friends
I want to get along better with my family
I want to have goals for my future
I want to feel better about myself
Other:

Intervention Specialist Checklist

Student's Name: Grade:___Date Referred:_________
Assigned Case Manager: Counselor:
Referring Staff: Planning Period:

After the initial referral, the following steps need to be taken:

Request students teachers to complete the B.O.S. no later than ( )
Compare previous report card with current grades
Examine cumulative folder
Look at attendance for patterns of absenteeism
Examine discipline folder and note consequences received by the student
Consult with nurse for pertinent information (if he or she has contact with student)
Consult with counselor for pertinent information (if he or she has contact with student)
Consult with administrator (if he or she has contact with student)
Staff case with Safe and Secure Schools Coordinator

Questions to Consider When Presenting/Screening Student Info:

1. Do the observed classroom behaviors indicate some sort of problem exists?

2. Is there additional data that supports the teachers' observations?

3. What has been done at school to resolve the concerns?

4. Have those efforts worked?

Intervention Strategies:
Based on the findings and available resources, the following plan of action is
recommended:____________________________________________________


Staff Feedback Form
Confidential

To Date

Subject: Intervention Specialist Referral

Student
In response to your recent Intervention Specialist referral, the referral has been screened and the
following services are recommended for the student (see strategies that have been checked): If
there is more you believe the Intervention Specialist can do, please let us know.

__Participation in a campus-based support group
__Individual counseling with
__Mentor from the community or campus
__Involvement with student mediation process
__Assessment interview with community resource
__Serve as a mentor for
__Schedule staffing with teachers on
Academic modifications
(date)
__Classroom modifications
Classroom observation by
__Tutorials with
__Participation in tutorials with
__Academic coaching with
__Serve as a tutor for
__Referral to special education
__Speech referral
__Content mastery
__Reading recovery
__Schedule change
__Alternative education
__Behavior management plan
__Positive re-enforcement
__Behavior modification
__No action; insufficient data available
__Refer again in Date:
__Other:____________________________________________________ _

Your participation in the Intervention Specialist services is appreciated. Though the process of
assisting the student has been activated, it may take time before positive change occurs; your
concerns may continue for a while. If you have any questions or additional observations, please
contact

, Intervention Specialist

Thank You for Your Concern!

cc: Principal

Intervention Speciali st Process Eval uat ion
School: Evaluation Period:
Coordinator:
Total number of referrals to the Intervention Specialist:

Where did the referrals originate? Tally the total number of referrals from each source (teacher,
counselor, etc.) and indicate the percentage for each area:
Referral Source Total for the year Percentage of total %
Teachers
Counselors
Administrators
Nurse
Special Education
504 Committee
Discipline violations
Attendance Officer
Parents or Guardian
Students or peers
Self
Community representative
Coach

What percentage of the referrals to the Intervention Specialist resulted in a recommendation
for:

Recommendation Total for the
year
Percentage of
total %

Of all students referred to the Intervention Specialist, what percentage demonstrated the
following:

Students Referred to the Intervention Specialist Percentage indicating
improvement
Increased attendance after referral
Improved grades after referral
Reduced discipline violations after referral

Trends:

Comments:


Student Tracking Record
Confidential

Is this pre referral data? , or post referral data?

Time period reflected on the report:

Student Information
Name Gender Age Grade Level

Referral Source (Place date of activity in the appropriate box below)
Teacher Staff Admin Counselor
Family
Peer Attendance Policy
Violation

Attendance Tardies Discipline
Violations
Grades

1
st

period

2
nd

period

3
rd

period

4
th

period

5
th

period

6
th

period

7
th

period

Notes:


Campus Impact
Confidential

School:

Time period reflected on report:

Measurables
Source of
Data
Year prior
to starting
IS services
End of
current
year

Standardized Test Average Score

Overall attendance rate

AEIS

Number of discipline violations

Principal

Overall failure rate

PEIMS/AEIS

Overall drop out rate

PEIMS

Incidents of violence

PEIMS

Incidents of vandalism

PEIMS

Student body GPA

Principal

Percentage of special education referrals
that qualify

PEIMS

Staff turnover rate
Human
Resources

Formal complaints from parents

Principal

Alcohol violations

SDFSC

Tobacco violations

SDFSC

Drug violations

SDFSC

Weapons violations

PEIMS


Intervention Specialist Staff Satisfaction Survey

Read each statement in the list below, and circle a number to indicate how much you agree or
disagree.

1 2 3 4 5
Strongly Disagree Disagree Somewhat Neutral Agree Somewhat Strongly Agree

1. The Intervention Specialist services seemto be helping students who participate
in them.
1 2 3 4 5

2. The information that students share is kept confidential by staff.
1 2 3 4 5

3. The information that students share is kept confidential by other students.
1 2 3 4 5

4. When a student is referred to the Intervention Specialist, they get help in a
timely fashion.
1 2 3 4 5

5. The Intervention Specialist is highly skilled.
1 2 3 4 5

6. The Intervention Specialist is knowledgeable.
1 2 3 4 5

7. The Intervention Specialist is interested in my perspective and responsive to
concerns I express.
1 2 3 4 5

8. I clearly understand the purpose of the Intervention Specialist services.
1 2 3 4 5

9. I clearly understand what makes an appropriate referral to the Intervention
Specialist.
1 2 3 4 5

10. I clearly understand the nature of the services provided by the Intervention
Specialist.
1 2 3 4 5

11. The Intervention Specialist does a good job training and educating the rest of
the staff.
1 2 3 4 5

12. The Intervention Specialist does a good job working with other resources
available in school.
1 2 3 4 5

13. The Intervention Specialist does a good job working with community resources.
1 2 3 4 5

14. Overall, my contacts with the Intervention Specialist have been positive.
1 2 3 4 5

15. If a student had a problem, I would recommend the Intervention Specialist as a
resource to get help.
1 2 3 4 5

16. The Intervention Specialist is a positive influence on this school.
1 2 3 4 5


Student Participant Satisfaction Survey

Read each statement in the list below, and circle a number to indicate how much you agree or
disagree.

1 2 3 4 5
Strongly Disagree Disagree Somewhat Neutral Agree Somewhat Strongly Agree

1. The individual counseling and/or group counseling I participated in were
interesting.
1 2 3 4 5

2. The information I shared in the group was kept confidential by staff.
1 2 3 4 5

3. The information that I shared with other students was kept confidential.
1 2 3 4 5

4. The Intervention Specialist knows what s/he are talking about.
1 2 3 4 5

5. The Intervention Specialist is good at what they do.
1 2 3 4 5

6. The Intervention Specialist show s/he cares about me personally.
1 2 3 4 5

7. I felt the reason I was receiving services was clearly explained to me.
1 2 3 4 5

8. I feel Ive made positive changes fromreceiving services.
1 2 3 4 5

9. The Intervention Specialists services helped me achieve my own goals.
1 2 3 4 5

10. I benefited fromthe Intervention Specialists services.
1 2 3 4 5

11. Overall, Imglad I participated in the Intervention Specialists services.
1 2 3 4 5

12. If I had a friend with a problem, Id recommend the Intervention Specialist as a
resource to get help.
1 2 3 4 5

13. The Intervention Specialists services have a positive influence on the school.
1 2 3 4 5

14. Overall, my contacts with the Intervention Specialist have been positive.
1 2 3 4 5


Intervention Specialist Action Plan

Strategies: Staff Responsible Needed Resources
Targeted
Completion
Date
Date
completed

1. Select
Program/Service/Activity/Strategy

2. Set meeting/training dates

3. Select time & place to meet

4. Prepare all forms

5. Update principal

6. Prepare summary of services

7. Choose how referral is received

8. Intervention Specialist services
description in handbook

9. Draft letter to parents

10. Introduce service to staff

11. Identify potential students

12. Meet and screen students

13. Administer pre-test

14. Begin program/activity/strategy

15. Provide student training (if needed)

16. Provide staff training (if needed)

17. Implement program

18. Check for modifications

19. Choose method for evaluating

20. Recruit and train new teammembers

21 Other,

22. Other;

23. Other;

24. Other;

Intervention Specialist Date

Intervention Specialist Forms: Aldine Independent School District Safe and Secure Schools

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