Student Identifying Information

Student Name:
Date of Birth:
Current Grade:
Teacher Name:
Meeting Date:
Additional Information

Primary Language Spoken at Home:

Primary Physician:
Medical Diagnoses:
Medications taken regularly:
School Attendance Patterns:
Prior Schools Attended:
Additional Student Strengths:
Other Information:

Problem Solving Meeting

Team Members Attending:

- Principal - K-2 Special Ed
- School Psychologist - K-2 EL
- Instructional Facilitator - 3-5 Special Ed
-Title I - 3-5 EL
- School Counselor

Define the Problem (use objective and concrete terms) (1 minute):

What data do we have to use as we discuss this student:

Example: progress monitoring data, graphed behavior data, percentage scored on daily work, quizzes, tests, etc. (2 minutes)

What could be the cause of the problem?

Example: Is instruction delivered with fidelity? How could we increase the intensity or length of instruction? How can we better
differentiate instruction? (2 minutes)

What prior Interventions have been utilized? (2 minutes)

What is our team decision? (2 minutes)

Intervention:
Leader:
Frequency:
Length of Intervention:
How will we monitor the intervention effectiveness?

Follow-Up Date: (1 minute)

Attending:

Teacher Report:

Reading:

Math:

Team Decision:

Follow-Up Date: (1 minute)

Attending:

Teacher Report:

Reading:

Math:

Team Decision: