<p> New Paltz Central School District Referral to Instructional Study Team Lenape Elementary Student Name: Grade: Date of Birth: Parent/Guardian: Address: Telephone: Referred by: Referral Date:</p><p>Is this student an English Language Learner? _____Yes ____ No</p><p>Prior IST Meetings (Grade + Month)</p><p>Reading Recovery Met Benchmark Did not meet Incomplete Program First grade only Benchmark</p><p>Remedial Reading K 1 2 3 4 5 Services</p><p>1. Reason for Referral (check as many as appropriate): _____ A. General academic concerns _____ B. Reading _____ C. Math _____ D. Written Expression _____ E. Fine Motor (i.e. Handwriting, cutting, etc.) _____ F. Speech/Oral Language _____ G. Social/Emotional/Behavior concerns (Please indicate your interest in having a member of the Crisis Team present _____ yes _____ no). _____ H. Work Habits _____ I. Attendance _____Absent ____ Tardy _____ Leaves Early _____ J. Listening skills _____ K. Others (please be specific) ______</p><p>2. Are you aware of any physical or medical problems which may affect the student’s functioning at school?</p><p>3. An administrator, regular education teacher, special education teacher and social worker will be attending the IST meeting. Please indicate on the following list any other support staff you would like present.</p><p>_____ Remedial Reading Teacher _____ Occupational Therapist</p><p>____ Speech/Language Teacher ______School Psychologist</p><p>_____ ESL _____ School Nurse _____ Other______</p><p>Please indicate any of the above staff with whom you have consulted, if any: </p><p>4. Please describe the student’s performance in the following areas. Be sure to include most recent test scores (i.e., NYS ELA, NYS Math, etc.), and all other assessment data:</p><p>Subject Area Reading</p><p>NYS ELA Test Score: _____ Date/Grade Taken: ______</p><p>Math</p><p>NYS Math Test Score: ______Date/Grade Taken: ______</p><p>5. Areas of Concern: (Please mark any that apply)</p><p>Academic Issues: Reading: ___Weak literal comprehension ___Weak Vocabulary ___Difficulty with phonics (omits, adds, substitutes, reverses letters, words or sounds when reading) ___Difficulty with fluency ___Reads below grade level</p><p>Writing: ___Difficulty with organizing written work ___Difficulty with mechanics of writing ___Difficulty with spelling ___Difficulty with written expression</p><p>Language: ___Difficulty expressing ideas verbally ___Needs questions or directions repeated ___Difficulty understanding abstract concepts</p><p>Math: ___Difficulty memorizing facts ___Weak calculation skills ___Difficulty with Multi-step problems ___Difficulty with reading impacts word problems </p><p>Organization: ___Does assignments/cannot find them ___Does not write down assignments ___Does not complete homework ___Comes to class without materials Behavioral Issues: ___Distractibility ___Impulsivity ___Social skills ___Non-compliance ___Aggression ___Insubordination ___Other:______</p><p>Psychosocial or Mental Health Concerns: ___Depression ___Suicidal thoughts/ideations ___Self-injurious behaviors ___Grief ___Self Esteem ___Anxiety ___Family Issues ___Peer difficulties ___New student having trouble with adjustment ___School Avoidance Other:______</p><p>Health Concerns:______Attendance: _____Frequently Absent ____ Frequently Tardy _____ Leaves School Early </p><p>6. Strengths: (Please check all that apply)</p><p>___Organized ___Math ___Good Study skills ___Good Writing Skills ___Friendly ___Reading ___Cooperative ___Good Verbal Skills ___Kind ___Artistic ___Musical ___Athletic ___Other:______</p><p>7. Are there certain activities that the student prefers to do/tends to excel at?</p><p>Procedural Check List:</p><p>When was contact made with the parent/guardian to discuss your concerns? ___/_____/____ What was the parent’s feedback?______</p><p>8. Did you inform the parent that you would be referring the student to IST? _____Yes______No</p><p>9. An administrator, social worker, classroom teacher and special education teacher will be present. Please indicate on the following list any other support staff you would like present.</p><p>______Speech Therapist ______Reading Teacher ______ELL Teacher ______Occupational Therapist ______Physical Therapy ______School Psychologist ______School Nurse ______Additional Classroom Teacher ______Other ______</p><p>______</p><p>Please indicate any of the above staff with whom you have consulted, if any: ______</p><p>______</p><p>10. What measures have you taken to assist the student? (Please describe at least 3)</p><p>Specific Strategy Implemented in the Classroom Frequency Beginning Ending Tier I and Performance Performance duration Small group instruction Targeted intervention based on similar needs</p><p>Guided Reading</p><p>1.1 Instruction 1-2 Targeted intervention based on similar needs</p><p>Graphic Organizers</p><p>Study Buddy</p><p>Positive Reinforcement</p><p>Language: Break down for understanding Check for comprehension Visual supports</p><p>Behavioral: Planned ignoring Preferential Seating Behavioral Checklist Reward System Planned Breaks Other </p><p>Behavior Intervention Plan</p><p>Breaking down tasks</p><p>Modified class work</p><p>Other (describe): Additional Comments:</p><p>11. What additional school and/or community resources have been used to assist this student?</p><p>Support Service Frequency Comments SUNY Literacy Program</p><p>Remedial Reading</p><p>Multisensory Approach</p><p>Supportive Counseling</p><p>OT/Sensory support</p><p>Reading Software</p><p>Summer School</p><p>Outside Tutoring</p><p>Speech and Language Services</p><p>Community Resources (list):</p><p>Other (describe):</p><p>12. Have you discussed your concerns with this student’s parents (describe nature of support)? Yes __ No__</p><p>13. What would you like to see happen as a result of this referral to the Instructional Study Team? ------TO BE COMPLETED BY INSTRUCTIONAL STUDY TEAM------</p><p>INSTRUCTIONAL STUDY TEAM PLAN </p><p>Date: Is this a revisit? Does this case need to be revisited? YES_____ NO_____ If yes, the revisit date will be: Will student be referred to CSE? YES____ IF YES, ENTER DATE______NO_____ Members Present: Background Information:</p><p>Student Needs/Goals:</p><p>STRATEGIES TO ACCOMPLISH THESE GOALS</p><p>* Person taking IST minutes, please initial here: _____ Intervention Implementation Frequency Time Start Date Progress Documentation Who? Where? Frame</p><p>IST Liaison______Check-in date______</p>