MTSS Issues with Learning and Behavior

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Todays Date*

MonthDayYear
Building*
Student Information

Please Enter the Student's Information Below
Student’s First Name*
Student’s Last Name*
Date of Birth*

MonthDayYear
Gender*
Grade*
Hispanic/Latino Ethnicity?*

YesNo
Race*
If Native American, is Indian Education Notified?*

YesNo
Student History Review

Please complete section two by referring to the student's CUM file, parent/guardian, guidance counselor, and/or student.
Parent/Guardian Name*
Address*
Phone Number*
History of Absenteeism?*

YesNo
Describe*
History of Retention?*

YesNo
Describe*
History of Behavioral Concerns?*

YesNo
Describe*
Does the Student have a Diagnostic Assessment or see a counselor?*

YesNo
Describe*
Physical or Medical Problems or Concerns?*

YesNo
Describe*
Vision Screening Conducted in Last 6 Months?*

YesNo
Describe*
Hearing Screening Conducted in Last 6 Months?*

YesNo
Describe*
Environmental, Diversity, or Family Factors Affecting Education?*

YesNo
Describe*
Outside Agency Evaluation?*

YesNo
Describe*
Previous Special Education Assessments?*

YesNo
Describe*
Previous Special Education Services?*

YesNo
Describe*
Previous Title 1/Assurance of Mastery or Other Services?*

YesNo
Describe as specifically as possible, listing previous interventions and/or accommodations if known (Reading Recovery, LLI, etc.)*
Date Parent/Guardian Contacted*

MonthDayYear
Person Making Contact*
Type of Contact*

Phone CallConference/Face-to-Face Visit
All Languages Spoken in the Home*
Child's First Language of Exposure*
(If Native American) Which best describes your connection to the districts Indian Education Program?*

We are registeredWe have declined servicesWe are interested in more information
Please ask the parent/guardian the following question: "As you think about your family's cultural or racial background, would you like the school staff to know anything specific about your child?" Record response below. *
If Vision and Hearing screenings have not been conducted in the past 6 months, inform parent/guardian that the screenings will be conducted. *

Parent was informed of vision/hearing screeningsNot necessary; screening has been done within past 6 months
Relevant Assessment Data (MCA, MAP, FAST, Curricular, Other):*
Checklist of Issues

Thank you for taking your time to fill this out. Please check up to the top 3 areas in which you have a concern.
Which is most needed?*

Mental HealthAcademic InterventionBehavior InterventionSpeech / LanguageOther
Primary Areas of Concern*

Memory, Abstractions, Generalizations, and OrganzationListeningSpeakingReadingWritingSpellingMathematical CalculationsAcademic PerformanceInterpersonal RelationshipsDepression/MotivationInappropriate Behavior Under Normal CircumstancesRules and ExpectationsGroup BehaviorSocial Skills/Communication
Do you have concerns in the following areas?*

Speech - Language or ArticulationMotor Skills - Fine or Gross MotorNo concerns in these areas
Areas of Concern (Detailed)

The page numbers listed correlate to possible interventions for the concern in the Pre-Referral Intervention Manual. Please only mark up to the top 3 concerns for each question.
Memory, Abstractions, Generalizations, and Organization

Is disorganized (11)Has limited memory skills (15)Has difficulty understanding abstract concepts (18)Fails to find locations in the building (20)Does not respond appropriately to environmental cues (22)Does not stay in assigned areas for specified time (24)Needs verbal questions and directions frequently repeated (26)Demonstrates difficulty with visual memory (31)Does not demonstrate an understanding of directionality (35)Has difficulty concentrating (36)Perseverates - does the same thing over and over (41)Fails to demonstrate logical thinking (43)Has difficulty retrieving, recalling, or naming objects, persons, paces, etc. (45)Demonstrates visual perception problems (48)Has difficulty classifying (50)Fails to generalize knowledge from one situation to another (51)Demonstrates confusion (53)Remembers information one time but not the next (55)Requires slow, sequential, substantially broken-down presentation of concepts (57)Fails to remember sequences (59)Other
Listening

Does not listen to or follow verbal directions (63)Does not hear word endings, does not hear key words such as "do not," etc (68)Does not direct attention or fails to maintain attention to important sounds in the immediate environment (72)Has difficulty differentiating speech sounds heard (75)Is unsuccessful in activities requiring listening (76)Attends more successfully when close to the source of sound (80)Requires eye contact in order to listen successfully (83)Does not listen to what other students are saying (86)Other
Speaking

Has difficulty imitating speech sounds (90)Omits, adds, substitutes, or rearranges sounds or words when speaking (92)Distorts or mispronounces words or sounds when speaking (not attributed to dialect or accent) (94)Does not use appropriate subject-verb agreement when speaking (96)Has a limited speaking vocabulary (98)Uses inappropriate verb tenses when speaking (102)Speaks dysfluently (104)Does not complete statements or express complete thoughts when speaking (107)Other
Reading

Does not comprehend what he/she reads (112)Fails to finish assignments because of reading difficulties (116)Fails to demonstrate word attack skills (119)Fails to recognize words on grade level (121)Loses place when reading (123)Has difficulty with sound-symbol relationships (125)Has difficulty with phonics skills when reading (126)Omits, adds, substitutes, or reverse letters, words, or sounds when reading (128)Fails to demonstrate word comprehension (130)Reads words correctly in one context but not in another (133)Does not read independently (134)Does not discriminate between similar letters and words (136)Does not know all the letters of the alphabet (137)Understands what is read to him/her but not what he/she reads silently (138)Has difficulty recalling the sequence of events in stories read (140)Does not demonstrate an understanding of alphabetical order (142)Has difficulty identifying the topic sentence and main idea when reading (143)Does not demonstrate an understanding of contractions and compound words (145)Fails to demonstrates glossary and dictionary skills (146)Has difficulty finding supporting details when reading (148)Other
Writing

Performs assignments so carelessly as to be illegible (151)Fails to copy letters, words, sentences, and numbers from a model at a close proximity (153)Fails to copy letters, words, sentences, and numbers from a model at a distance (156)Fails to use capitalization correctly when writing (158)Uses inappropriate spacing between words or sentences when writing (160)Reverses letters and numbers when writing (161)Fails to write within a given space (163)Fails to punctuate correctly when writing (165)Does not use appropriate subject-verb agreement when writing (167)Does not compose complete sentences or express complete thoughts when writing (169)Fails to correctly organize writing activities (172)Omits, adds, or substitutes words when writing (!74)Fails to form letters correctly when printing or writing (176)Fails to use verb tenses correctly when writing (178)Uses inappropriate letter size when writing (180)Other
Spelling

Fails to use spelling rules (183)Has difficulty with phonetic approaches to spelling (185)Omits, substitutes, adds, or rearranges letters or sound units when spelling words (187)Has difficulty spelling words that do not follow the spelling rules (189)Does not use word endings correctly when spelling omits them (191)Spells words correctly in one context but not in another (192)Requires continued drill and practice to learn spelling words (194)Other
Mathematical Calculations

Has difficulty solving math word problems (197)Fails to change from one math operation to another (200)Does not understand abstract math concepts without concrete examples (202)Fails to correctly solve math problems requiring regrouping (i.s., borrowing and carrying) (204)Works math problems from left to right instead of right to left (206)Fails to follow necessary steps in math problems (208)Fails to correctly solve math problems involving factions or decimals (211)Fails to demonstrate knowledge of place value (213)Confuses operational signs when working math problems (214)Fails to correctly solve problems involving money (215)Fails to correctly solve problems using measurement (217)Does not understand the concept of skip counting (219)Cannot tell time (220)Fails to correctly solve math problems requiring addition (221)Fails to correctly solve math problems requiring subtraction (223)Fails to correctly solve math problems requiring multiplication (225)Fails to correctly solve math problems requiring division (227)Does not remember math facts (229)Does not make use of columns when working math problems (231)Other
Academic Performance

Does not perform or complete classroom assignments during class time (234)Fails to complete homework assignments and return them to school (240)Fails to perform tasks or assignments independently (245)Performs classroom tests, quizzes, or tasks at a failing level (248)Does not prepare for assigned activities or daily routines (250)Does not remain on-task for the required length of time (255)Does not perform academically at his/her ability level (260)Does not read or follow written directions (265)Is reluctant to attempt new assignments or tasks (268)Requires repeated drill and practice to learn what other students master easily (271)Does not function appropriately in the presence of verbal and physical stimuli in the classroom (273)Rushes through activities or assignments with little or no regard to accuracy, quality, or neatness (275)Fails to make appropriate use of study time (279)Begins an assignment or activity before receiving or reading complete directions or instructions or fails to follow directions or instructions (284)Changes from one activity to another without finishing the first, without putting things away, before it is time to move on, etc. (288)Does not begin assignments after receiving directions, instructions, etc.. (291)Does not complete assignments after receiving directions, instructions, etc.. (294)Other
Interpersonal Relationships

Makes inappropriate comments or unnecessary noises in the classroom. (297)Fights with other students (301)Becomes physically aggressive with teachers (304)Makes unnecessary physical contact with others (307)Makes inappropriate comments to teachers (309)Responds inappropriately to praise or recognition from other students or teachers (312)Is easily angered, annoyed, or upset (314)Agitates and provokes peers to a level of verbal or physical assault (320)Has little or no interaction with teachers (322)Has little or no interaction with peers (325)Makes inappropriate comments to other students (328)Responds inappropriately to typical physical exchanges with peers (331)Does not respond appropriately to friendly teasing. (333)Is not accepted by other students. (335)Bothers others who are trying to work, listen, etc. (338)Responds inappropriately to others' attempts to be friendly, complimentary, sympathetic, etc. (342)Refuses to share possessions or materials. (344)Does not allow others to take their turn or participate in activities or games, etc. (347)Does not demonstrate the ability to resolve conflict situations (349)Does not make appropriate use of free time (351)Fails to work appropriately with peers in a tutoring situation (353)"Gets Back" at others when he/she feels that someone has wronged hi/her. (355)Writes and passes notes (358)Tattles (359)Grabs things away from others (361)Interrupts the teacher or other students (363)Other
Depression/Motivation

Has unexcused absences (367)Has unexcused tardiness (369)Blames other persons or materials to avoid taking responsibility for his/her mistakes or failures (371)Does not participate or demonstrate an interest in classroom activities or special events that are interesting to other students (373)Blames self for situations beyond his/her control (376)Expresses concerns or worries about school, home, or personal situations through words or pictures (377)Is not motivated by rewards (379)Responds inappropriately to constructive criticism or comments from others (380)Tries to avoid situations, assignments, responsibilities (380)Demonstrates self-destructive behavior (385)Threatens to hurt self or commit suicide (387)Indicates that no one likes him/her, no one cares about him/her, etc (389)Ignores consequences of his/her behavior (392)Does not smile, laugh, or demonstrate happiness (395)Cheats (397)Throws temper tantrums (399)Is tired, listless, apathetic, unmotivated, not interested in school (401)Indicates that he/she does not care or is not concerned about performance, grades, report cards, graduating, consequences of behavior, etc. (403)Is overly critical of self in school-related performance, abilities, personal appearance, etc. (405)Frowns, scowls, looks unhappy during typical classroom situations (407)Needs immediate rewards, reinforcement, or gratification in order to demonstrate appropriate behavior (409)Does not care for personal appearance (411)Is pessimistic (414)Physically runs away from personal or school experiences (416)Cries in response to personal or school situations (418)Other
Inappropriate Behavior Under Normal Circumstances

Behaves inappropriately when others do well or receive praise or attention (421)Does not behave in a manner appropriate for the situation (423)Acts impulsively without apparent self-control (425)Exhibits sudden or extreme mood changes (427)Is unpredictable in behavior (429)Makes sexually related comments or engages in inappropriate behavior with sexual overtones (432)Moves about unnecessarily (434)Becomes overexcited (437)Lies, denies, exaggerates, distorts the truth (440)Speaks in an unnatural voice (442)Speaks incoherently (443)Engages in nervous habits (445)Destroys school, teachers', or other students' property (447)Does not accept changes in an established routine (450)Reacts physically in response to excitement, disappointment, surprise, happiness, fear, etc. (453)Enages in inappropriate behaviors related to bodily functions (455)Becomes pale, my vomit, or pass out when anxious or frightened (457)Demonstrates phobic reactions (459)Does not change from one activity to another without difficulty (461)Cannot fasten articles of clothing (463)Does not change clothing for physical education (464)Does not demonstrate appropriate mealtime behavior (466)Other
Rules and Expectations

Uses obscene or profane language (469)Does not demonstrate the ability to follow a routine (473)Does not take appropriate care of personal property (476)Steals or forcibly takes things from other students, teachers, the school building, etc. (479)Engages in inappropriate behaviors while seated (482)Does not follow directives from teachers or other school personnel (485)Brings inappropriate or illegal materials to school (487)Responds inappropriately to redirection in academic and social situations (489)Does not follow school rules (491)Demonstrates inappropriate behavior on the school grounds before and after school (494)Does not follow classroom rules (496)Does not wait appropriately for an instructor to arrive (498)Does not wait appropriately for assistance from an instructor (499)Does not wait appropriately for assistance from an instructor (499)Does not demonstrate appropriate us of school-related materials (501)Does not demonstrate appropriate care and handling of others' property (504)Does not raise hand when appropriate (507)Demonstrates inappropriate behavior going to and from school (509)Does not take notes during class when necessary (510)Is preoccupied with drugs or alcohol or possesses or uses drugs or alcohol at school (512)Blurts out answers without being called on (514)Interrupts others (517)Talks to others during quiet activity periods (520)Leaves seat or assigned area without permission (522)Does not come to or is not ready for an activity at the specified time (525)Other
Group Behavior

Demonstrates inappropriate behavior when moving with a group (528)Behaves more inappropriately alone or in small groups than with the whole class or in large croup activities (530)Demonstrates inappropriate behavior in a small academic group setting (533)Does not demonstrate appropriate behavior in the presence of a substitute authority figure (536)Demonstrates inappropriate behavior in a large academic group setting (539)Has difficulty working effectively in a group situation (542)Does not demonstrate appropriate behavior in a group games (546)Other
Social Skills/Communication

Has difficulty interacting/playing with others (550)Prefers to play alone (556)Does not exhibit awareness of social "codes of conduct" or does not learn appropriate behavior form observing such behaviors (560)Does not realize how his/her actions affect others (565)Does not use other's emotional responses to guide behavior (571)Has difficulty identifying personal space preferences of others (575)Is not loyal to friends and organized groups (579)Exhibits unusual facial expressions (581)Demonstrates difficulty maintaining topic of conversation (583)Remains fixated on personal topics of interest in conversation with others (586)Is unable to interpret nonverbal facial cues of others (589)Does not communicate for the purpose of sharing positive affect (593)Is unable to participate in conversational turn taking (597)Has difficulty understanding or accepting others' point of view (603)Stares off into space (608)Does not adjust behavior to the demands of the social situation (612)Engages only in activities which focus on personal topics of interest (614)Responds inappropriately to environmental social cues (621)Lacks spontaneity, originality, and/or variety in verbal interactions (624)Is slow to respond and/or fails to respond with relevant responses (627)Uses inappropriate verbal and/or nonverbal language in social situations or interactions with peers and/or adults (629)Uses inappropriate verbal and/or nonverbal language in social situations or interactions with peers and/or adults (629)Demonstrates difficulty expressing logical and reasonable responses to questions (632)Has difficulty expressing opinions, feelings, and/or emotions (634)Has difficulty using realistic greetings/closings when appropriate (636)Exhibits difficulty using verbal language as a tool to obtain desired results (638)Can only speak in short, simple sentences which lack complexity (639)Has difficulty understanding directions and/or carrying out instructions and often requires repetition or rephrasing (641)Has limited expressive and/or reception vocabulary (644)Has difficulty understanding nonliteral forms of speech such as idioms, proverbs, similes, metaphors, jokes, puns, and riddles (647)Says one thing, but means another (649)Has difficulty producing information required in a specific situation (653)Other
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Student Information

Student History Review

Checklist of Issues

Areas of Concern (Detailed)