PLEASE Make a COPY first

BEFORE filling out

Jefferson SST

Problem Solving Team

Instructions:

First, make a copy of this form by going to File, then Make A Copy. Name the form with the students name. Please
fill out form items down to the dotted line. Then send this document

to jefferson-pst@isd77.k12.mn.us

by the end of the day Friday

prior to your scheduled PST meeting time. This allows an opportunity for our team to review the information prior to your meeting
time. At the PST meeting, we will have 15
minutes to discuss/problem solve/review or create interventions. Thank you!

Student Information
Name:
Grade:
DOB:

Referral Date:
Current Teachers Name:
Previous PST Record?: __Yes

__No

Parents contacted about concerns?

Parents contacted about placement changes/moves?
Notes (if any):
Background Information: (i.e. recently moved, attendance, health info, etc.):
Reason for PST visit:

Student Strengths:
Most Recent Assessment Data
DIBELS Next

__Fall
__Winter
__Spring
FSF:
NWF (CLS):
DORF:
LNF:
NWF (WWR):
Retell:
Retell Quality:
PSF:
Daze:

Progress
Monitoring

Measure: Rate of Improvement (ROI):

*See attached graph see progress monitoring data

NWEA

Reading: __Fall __Winter __Spring

Math: __Fall __Winter __Spring

MCA

Reading Score:
Math Score:

RIT:
RIT:

% Accuracy:

Percentile:
Percentile:

Support Information
Reading:
*See Grade Level Reading Problem Solving Form.
*Remember to bring DIBELS progress monitoring and trendline data and/or formative assessment
data.
Behavior:
*See Grade Level Behavior Problem Solving Form.
*Remember to bring any progress monitoring data.
Reading:
Intervention

Who
Implements?

Days per
week?

Minutes
per day?

Fidelity
Check

Start Date

End Date

*Fidelity Check includes: The number of checks and the average score of each check. Minimum of 1
Fidelity Check per intervention in a 12-week period.
Math:
Intervention

Who
Implements?

Days per
week?

Minutes
per day?

Fidelity
Check

Start Date

End Date

*Fidelity Check includes: The number of checks and the average score of each check. Minimum of 1
Fidelity Check per intervention in a 12-week period.

Behavior:
Intervention

Who
Implements?

Days per
week?

Minutes
per day?

Fidelity
Check

Start Date

End Date

*Fidelity Check includes: The number of checks and the average score of each check. Minimum of 1
Fidelity Check per intervention in a 12-week period.

Other Supports Currently Occurring

_ Accommodations (i.e. preferential seating, extra time, reduced workload). Please list.
__ School Counselor
__ Excel
__ School Social Worker
__ Mentor Program
__ ELL
__ Big Brother/Big Sister
__ Cultural Liaison
__ Prior special education evaluation
__ County Social Worker/Skills Worker/Guardian Ad Litem
__ Attendance concerns
__ Community Psychologist/Psychiatrist/Counselor
__ Other:

STOP HERE. THANK YOU!

INTERVENTION PLAN
SMART Goal:

Intervention Description/Title:

Concern addressed: Reading [Phonemic Awareness, Phonics/Decoding, Fluency,

Comprehension, Vocabulary] and/or Behavior:

Days Per Week:

Person Delivering Intervention:

Progress Monitoring Tool: __DIBELS Next
__ODRs
__Other:

Minutes Per Day:

__Daily Behavior Chart

__Majors/Minors

Data Collector: __Classroom Teacher __SSC __Interventionist __Counselor __Other:

Frequency of Data Collection:

__Daily

__1x per week

__1x biweekly

__Other:

Baseline Data:
Goal by Review Date:
(How do we know the intervention was effective? Think data-driven goal.)

Goal by End of Year (use goal set at the beginning of the year):
Intervention Start Date:
Review Date:
(Typically 8 weeks of data with intervention fully implemented. Be sure to record this date on your Meeting Calendar)

Fidelity Check Date (2 weeks after intervention start date):

Who:

A fidelity check must be done for every intervention to ensure the intervention was implemented as described in intervention plan.

Additional Intervention Notes:

Evaluate the Plan
Review Date:
Intervention implemented as described?: __Yes __No
Goal Progress: __Below Target __On Target __Above Target
Progress Monitoring Graph (see attached)
Continue intervention? __ Yes Goal by Review Date:
Review Date:
__ No P
lan (i.e. increase intervention intensity, change intervention):
Justification for decision (data-based):

Review Date:
Intervention implemented as described?: __Yes __No
Goal Progress: __Below Target __On Target __Above Target
Progress Monitoring Graph (see attached)
Continue intervention? __ Yes Goal by Review Date:
Review Date:
__ No P
lan (i.e. increase intervention intensity, change intervention):
Justification for decision (data-based):