Special Circumstances Instructional Assistance Rubric

Student Name: DOB: Disability: Date Reviewed:

Teacher: Current Program: Person Completing Rubric (Name/Title): Select the number that best describes the student in each rubric category that is appropriate.

0 Health/Personal Care/Rating Behavior/Rating Instruction/Rating Inclusion/Mainstreaming/Rating e

0 General good health. No specialized Follows adult directions without frequent Participates fully in whole class Participates in some core curriculum 1

4 0 C health care procedure, medications taken, or prompts or close supervision. Handles instruction. Stays on task during typical within general education class and requires O time for health care. Independently change and redirection. Usually gets along instruction activity. Follows direction with few modifications. Can find classroom. N N maintains all “age appropriate” personal with peers and adults. Seeks out friends. few to no additional prompts. Usually socializes well with peers. O C E care. R N S 1 Mild or occasional health concerns. Follows adult direction but occasionally Participates in groups at instructional Participates with modifications and Allergies or other chronic health conditions. requires additional encouragement and level but may require additional prompts, accommodations. May need occasional M No specialized health care procedure. prompts. Occasional difficulty with peers or cues, or reinforcement. Requires reminders reminders of room and schedule. Requires I Medication administration takes less than adults. Does not always seek out friends but to stay on task, follow directions and to some additional support to finish work and L D 10 minutes time. Needs reminders to plays if invited. Can be managed adequately remain engaged in learning. be responsible. Needs some social cueing complete “age appropriate” personal care with a classroom behavior management plan. to interact with peers appropriately. activities. 2 Chronic health issues, and generic Has problems following directions and Cannot always participate in whole class Participates with visual supervision and specialized health care procedure. Takes behaving appropriately. Unable to instruction. Requires smaller groups and occasional verbal prompts. Requires visual

S M medication. Health care intervention for experience much success without individual frequent verbal prompts, cues or shadowing to get to class. Needs

t e O p 10-15 min. daily (diet, blood sugar, Behavior Support Plan (BSP) reinforcement. On-task about 50% of the modifications and accommodations to

medication). Requires reminders and implementation. time with support. Requires more verbal benefit from class activities. Regular

F R additional prompts or limited hands-on prompts to follow directions. socialization may require adult facilitation.

m assistance for washing hands, using T

2 E bathroom, wiping mouth, shoes, buttons, zippers, etc. Occasional toileting accidents. 3 Very specialized health care procedure Serious behavior problems almost daily. Difficulty participating in a large group. Participation may require additional staff and medication. Limited mobility. Defiant and/or prone to physical aggression. Requires low student staff ratio, close adult for direct instructional and behavioral S Physical limitations requiring assistance Requires a Behavior Intervention Plan (BIP) proximity and prompts including physical support. Requires direct supervision going I (e.g., stander, walker, gait trainer, and behavior goals and objectives on the IEP. assistance to stay on task. Primarily to and from class. Always requires G N wheelchair). Special food prep or feeding. Requires close visual supervision to complies only with 1:1 directions and modifications and accommodations for class I Health related interventions 15-45 min. implement BIP. Medication for monitoring. Cognitive abilities and skills work. Requires adult to facilitate social F daily. Frequent physical prompts and ADD/ADHD or other behaviors. Safety likely require modifications not typical for interaction with peers. I C assistance for personal care. Food prep issues are present. class as a whole. Needs Discrete Trial, ABA, A required regularly. Requires toilet schedule, structured teaching, PECS, etc. Requires N training, direct help, diapering, etc. signing over 80% of time. T 4 Specialized health care procedure Serious behavior problems with potential Cannot participate in a group without Always requires 1:1 staff in close requiring care by specially trained employee for injury to self and others, runs-away, constant 1:1 support. Requires constant proximity for direct instruction, safety, S (G tube, tracheotomy, catheterization). aggressive on a daily basis. Functional verbal and physical prompting to stay on-task mobility or behavior monitoring. Requires E Takes medication requires positioning or Analysis Assessment (Hughes Bill) has been and follow directions. Regularly requires 1:1 assistance to go to and from class 80% V E bracing multiple times daily. Health related completed and the student has a well- specific 1:1 instructional strategies to benefit of the time. Requires adult to facilitate R intervention 45 min. daily. Direct developed BIP, which must be implemented from the IEP. Cognitive abilities and skills social interaction with peers and remain in E assistance with most personal care. to allow the student to safely attend school. require significant accommodations and close proximity at all times. Requires two-person lift. Direct 1:1 Staff has been trained in the management of modifications not typical for the class group. assistance 45 or more minutes daily. assaultive behaviors.