Prior Lake Savage Area Schools

Problem Solving Model

Documenting Paper Work
2016-2017
Student Name: C.G. Date Referred to PST: March 2017

Prior Lake Savage Area Schools Teacher Interview

Date: Click here to enter text. Student: Click here to enter text.

Interviewer: Click here to enter text. Interviewee: Click here to enter text.

What strengths have you identified regarding this student? Click here to enter text.

In the area of referral, list the concerns for this student? Click here to enter text.

Define the concern in measurable terms. What is the district expectation and where is the student performing. Click
here to enter text.

List the data that supports the referral. Click here to enter text.

If this problem were magically fixed tomorrow, what would look different for this student? Click here to enter
text.

Updated 6/15/2015
Student Name: C.G. Date Referred to PST: March 2017

Problem Identification
Prior Lake-Savage Area Schools
Problem Analysis
Meeting Date: Click here to enter a date.

Step 1: Problem Identification: Determine what the discrepancy is between what is expected and what is occurring.

Discrepancy Statement: Click here to enter text.

Step 2: Problem Analysis: Why is the problem occurring?

Hypothesis: Click here to enter text.

Click Here for ICEL and RIOT examples

ICEL Hypotheses
Instruction Click here to enter text.
Curriculum Click here to enter text.
Environment Click here to enter text.
Learner Click here to enter text.

Hypotheses Review Interview Observe Test

Instruction
Curriculum
Environment
Learner

Updated 6/15/2015
Student Name: C.G. Date Referred to PST: March 2017

Prior Lake Savage Area Schools Plan Development

Plan Development Date: Click here to enter a date.

Intervention #: Choose an item. Area of Concern: Reading Math Writing Behavior

Goal: Click here to enter text.

INTERVENTION
Brief Description: Click here to enter text.
Description of Click here to enter text.
Needed Materials:
Interventionist: Click here to enter text.
When: Click here to enter text.
Where: Click here to enter text.
How Often: Click here to enter text.

MEASUREMENT SYSTEM
Data Collection Click here to enter text.
System:
Data Collector: Click here to enter text.
What Will Be Click here to enter text.
Recorded?
Frequency of Data Click here to enter text.
Collection:
When will Data be Click here to enter text.
Collected?

Intervention Start Date: Click here to enter a date.

Team Liaison: Click here to enter text.

Mid-Point Check Date: Click here to enter a date. Interview Observation

Review Date: Click here to enter a date. Time: Click here to enter text. Place: Click here to enter text.

Updated 6/15/2015
Student Name: C.G. Date Referred to PST: March 2017

Prior Lake Savage Area Schools Plan Implementation Evaluation

Review Date: Click here to enter a date.

Intervention #: Choose an item. Area of Concern: Reading Math Writing Behavior

Attach completed, dated intervention script observation form from initial observation

INTERVENTION PROTOCOL INTEGRITY

Team agrees that the written Team agrees that the written intervention script did not fully match
intervention script fully matched the the implemented intervention from the initial observation
implemented intervention.
Describe all revisions made to the intervention script:

Attach completed, dated intervention script observation form after

revisions were made documenting intervention integrity.

PLAN LOGISTICS INTEGRITY

Team agrees that the intervention
occurred for the number and
duration of sessions as designed on
the plan development form.
Team agrees that the intervention did not occur for the number and
duration of sessions as designed on the plan development form.
Describe differences between planned and actual intervention session
number and length:

Updated 6/15/2015
Student Name: C.G. Date Referred to PST: March 2017

Prior Lake Savage Area Schools Plan Evaluation

Plan Evaluation Date: Click here to enter a date.

Plan Evaluation:
Intervention #: Choose an item. Area of Concern: Reading Math Writing Behavior

Attach graph of student progress data

The current intervention began on Click here to enter a date. and continued through Click here to enter a
date..

Number of data points being considered during this intervention phase? Click here to enter text.

1. As a result of this intervention implementation:

Goal was met
Discrepancy decreased
Discrepancy stayed the same
Discrepancy increased

2. In the team's opinion, was the plan responsible for any change?
Yes
No

3. The next steps for the team will be to:

Discontinue intervention goal met
Maintain or generalize current plan
Select a new problem
Select a new hypothesis for the same problem
Retain current hypothesis, but modify the intervention plan
Continue problem solving and consider a referral for special education

Notes/Comments:
(If additional space is needed; the form will expand to include notes)

Next Meeting Date: Click here to enter a date.

Updated 6/15/2015