General Ed Behavior Help Ticket (Received by Tier 3 Coordinator)

STOP

Please ensure the student you are submitting this form for has been provided Tier 2 interventions and is still below 80% daily data collection.

Date: * +

Administrator Requesting Support: *

Email: *

Grade Span: *

Elementary

Middle

High

Building Name: *

Teacher Name: *

What help is being requested? *

Individual Student Support

Student Name: *

Grade: *

Upload fidelity data related to interventions collected on the student to this point (PDF or Word Doc): *

Additional data if applicable (PDF or Word Doc):

Mark behaviors of concern (check all that apply): *

What Tier 3 supports are currently in place? *

None or just referred to Tier 3 team (STOP! go back to Tier 2)

ABC data forms filled out

BIP developed

BIP implemented

FACTS interview complete

FBA developed

Parent contact has been made about the need for Tier 3 supports

Preference assessment completed

Two weeks of data has been collected around established goal areas

What Tier 3 supports are you wanting assistance in implementing? *

What parties are involved in current supports (check all that apply)? *

Outside Services: *

Any additional information we need to know?

Next Steps:

1. Tier 3 coordinator will review BCCR and reach out for additional information (will respond within 24 hours).

2. Once the Tier 3 coordinator has all necessary information they will set up a meeting with a building principal to determine next steps (meeting will take place within one week of Tier 3 coordinator's initial response).

3. Tier 3 coordinator will work to establish and/or adjust the existing plan with the building's Tier 3 team.

4. Will work with the Tier 3 team for ongoing data monitoring and support.

NON-DISCRIMINATION STATEMENT:

The Sioux City Community School District offers career and technical programs in the following areas: Business & Marketing, Family & Consumer Science, Health Science, and Industrial Arts, Technology, & PLTW.

The Sioux City Community School District is an equal opportunity/affirmative action employer and does not discriminate on the basis of race, creed, color, sex, sexual orientation, gender identity, genetic information (for employment), national origin, religion, age (for employment), disability, socioeconomic status (for programs), marital status (for programs), or veteran status (for employment) in its educational programs and its employment practices. The District is required by Title IX and 34 CFR Part 106 not to discriminate on the basis of sex in its programs, activities, or employment.

Inquiries or grievances under Section 504 and Title II of the Americans with Disabilities Act may be directed to Dr. Dora Jung, Director of Student Services & Equity Education/Title IX Coordinator at 627 4th Street, Sioux City, IA 51101, (712) 279-6075, jungd@live.siouxcityschools.com. Inquiries about the application of Title IX and its regulations to the District may be referred to the Title IX Coordinator, the Assistant Secretary of the U.S. Department of Education, or both. Please see District Board policies 103 and 504.4 for additional information on available grievance procedures.