CCJS - M-Team Data Form - Updated 07/2025

Multi-disciplinary Team Data Form

Clinton County Joint Services
Name of Student*
Grade*
School*
Age*
Teacher*
Assurances
Has the student been provided with appropriate instruction in reading and math?
YesNo
Explain*
YesNo
Explain*
Has the student received instruction in reading and math from a highly qualified teacher?
YesNo
Explain*
YesNo
Explain*
Was instruction provided using the same curriculum that was used with all students?
YesNo
Explain*
YesNo
Explain*
YesNo
Explain*
YesNo
Explain*
SCHOOL DATA
School Attendance: Frequent absences Frequent counselor visits #Other:
Frequent absencesFrequent tardiesFrequent nurse visitsFrequent counselor visitsOther
Number of absences
Number of tardies
Number of nurse visits
Number of counselor visits
Previous Schools Attended*
YesNo
Explain*
Discipline Record (please attach): school suspensions #
Office referralsin-school suspensionsout of school suspensionshistory of expulsion
Number of referrals
Number of in-school suspensions
Number of out-school suspensions
History of Expulsion
Known medical concerns/diagnoses?YesNo List:
YesNo
List*
YesNo
List*
Vision Screening
Date

MonthDayYear
Date
Administered By
Right - Far
Right - Near
Left - Far
Left- Near
With Glasses
Without Glasses
YesNo
Hearing Screening
Date*

MonthDayYear
Date
Administered By*
Right - 1000 Hz*
Right - 2000 Hz*
Right - 4000 Hz*
YesNo
Left - 1000 Hz*
Left - 2000 Hz*
Left - 4000 Hz*
YesNo
Students Strengths*

Current Grades

Rows	Grade	Comments on Strengths or Weaknesses
Math
Reading
Writing/Spelling
Science
Social Studies
Specials
Other

State and Local Assessment Results

Include most current and previous results. Include the student score as well as expected score/benchmark/passing score.

ISTEP/ECA:

Rows	Date	Subject Area	Score	Score Needed for Passing
ISTEP/ECA
Additional Attempts
Additional Attempts
Additional Attempts

Name of Local Test (e.g., NWEA, Acuity, OLSAT, DIBELS, mClass, STAR, etc.)

Rows	Date	Subject Area	Score	Expected/Benchmark/Passing/Grade Equiv/Percentile
Local Test
Local Test
Local Test
Local Test

Name of Local Test (e.g., NWEA, Acuity, OLSAT, DIBELS, mClass, STAR, etc.)

Rows	Date	Subject Area	Score	Expected/Benchmark/Passing/Grade Equiv/Percentile
Local Test
Local Test
Local Test
Local Test

Name of Local Test (e.g., NWEA, Acuity, OLSAT, DIBELS, mClass, STAR, etc.)

Rows	Date	Subject Area	Score	Expected/Benchmark/Passing/Grade Equiv/Percentile
Local Test
Local Test
Local Test
Local Test

Name of Classroom Based Assessments

Rows	Date	Subject Area	Score	Expected/Benchmark
Class-based Test
Class-based Test
Class-based Test
Class-based Test

Intervention Plan
Subject*
Form of data collect (AIMSweb, Easy CBM, behavioral log, DIBELS, etc.)*
Was the fidelity of administration and scoring of data collected checked YesNo Was the fidelity of core curriculum delivery checked?YesNo Was the fidelity of intervention delivery checked?YesNo Date Data Collected: Baseline Data Results:
YesNo
YesNo
YesNo
Date Data Collected*

MonthDayYear
Date
Baseline Data Results*
Research-based materials/strategies used for intervention:*
Group size*
Minutes/session*
# of days/wk provided:*
Interventionist*
Date Data Collected*

MonthDayYear
Date
Progress Monitoring Results*
Research-based materials/strategies used for intervention*
Group size*
Minutes/session*
# of days/wk Provided*
Interventionist*
Date Data Collected*

MonthDayYear
Date
Progress Monitoring Results*
PART 2: Behavioral Checklist
Name of Student*
Grade*
School*
Age*
Teacher*
General Areas of Concern*
Phonemic AwarenessWord IdentificationVocabularyReading ComprehensionReading FluencyWritten ExpressionWriting MechanicsWriting ConventionsOral ExpressionListening Comprehension
Number SenseMath FactsProblem SolvingWord ProblemsGeometryMeasurementProbabilityAnalysisOther
Motor SkillsSensory IntegrationSpeech/LanguageEating HabitsSleep HabitsOther
Doesn't comprehend what is being saidIsn't able to express self verballyDoes not initiate or sustain conversationsLow vocabularyInterprets figurative language literallyOther
Doesn't know basic factsDoesn't compute math problems correctlyLacks problem solving skillsTrouble remembering measurements, formulas, etc.Other
Lacks organization/loses thingsDoes not complete workDoes not complete homeworkPerforms poorly on tests and quizzesDoes not participate in classOther
SmellTactileHearing/VestibularTasteVisual processingOther
Doesn't read smoothly or fluentlyDoesn't decode new wordsDoesn't use context to discern word meaningIsn't able to make inferencesCannot retell selection using own wordsDoesn't comprehend silent readingDoesn't enjoy reading
Doesn't exhibit grade appropriate grammar in writingDoesn't exhibit ability to stay on topic in writingIs not able to express complete thoughts in writingIs not able to organize thoughtsLacks ability to draft thoughts before writingOther
Spells words incorrectly on weekly testsDoesn't apply phonetic rules in spellingDoesn't retain words previously learnedMisspells high frequency words in writingOther
Can't hold utensils for writingNot apply appropriate writing pressureWrites too slowlyTrouble with a variety of fine motor taksOther
Difficulty with balanceDifficulty with coordinationDifficulty with gait/ambulationOther
Behavior
Describe any behavioral concerns or classroom management issues:*
Fidgets, is easily distractedDifficulty staying seatedShifts quickly from one activity to anotherPoor concentration/difficulty sustaining attentionDifficulty following instructionsEngages in impulsive behaviorShifts from one activity to another
Talks excessively, interrupts often, doesn’t listenBlurts out answers before question is completedOften loses things, very disorganizedHas difficulty waiting his/her turn or in lineDifficulty initiating tasksDifficulty completing tasksDifficulty working independently
Avoids group activitiesControls group activitiesDifficulty working in groupsDepressed/sad moodDisoriented, confused, staring or “spacey”Sleeping in class
Difficulty playing quietlyEngages in physically dangerous activitiesDoes not have a preferred friendShy/withdrawnLittle or no interest in peersFeelings of worthlessness or low self-esteem
Low energy/fatigueExcessive separation difficultiesDoes not acknowledge personal space of othersPoor appetiteOvereatsOverly anxious, worrisome, or fearful
Often is loudDeliberately annoys othersCries easilyArgumentative with adultsArgumentative with peersSuicidal thoughts/acts
Temper tantrumsRapid mood changes/mood swingsDefies adult requests and rulesAngry/resentfulOften complains about bodily achesDifficulty making decisions
Blames others for mistakesPhysically aggressive towards peersPhysically aggressive towards adultsEasily frustratedPerseverates on ideasGravitates toward inappropriate peer groupsExcessive need for reassurance
LiesSubstance abuse drugsSubstance abuse alcoholStereotyped mannerismsAtypical/unusual fascinations or thoughtsDestroys others’ propertyInappropriate touching of self
StealsOften swears or uses obscene languageCompulsive ritualsHallucinations: VisualHallucinations: AuditorySelf-mutilation/self-injuryInappropriate touching of others
Comments regarding homework/assignment completion:
Comments/concerns regarding organizational skills:
Miscellaneous comments or conerns:
Should be Empty:

Multi-disciplinary Team Data Form

Assurances

SCHOOL DATA

Vision Screening

Hearing Screening

State and Local Assessment Results

Intervention Plan

PART 2: Behavioral Checklist

Behavior