Intervention Process Checklist

Pre-referral Documentation (must be completed and submitted prior to initial SAT meeting):

_____ Tier I Implemented for at least 4 – 6 weeks

_____ Tier II Implementation for at least 4 – 6 weeks

_____ Documentation of effectiveness of the interventions

_____________________________________________________________________________

Initial Tier 3 Meeting (SAT)

Date: _______________

_____ Vision/Hearing Screening completed prior to meeting

Passed Vision: Yes No Passed Hearing: Yes No

_____ Parent Input Form

_____ Tier III Implemented

_____ Other documentation forms as necessary.

Action taken: ___ Continue Interventions ___ Modify Interventions

Follow-up SAT Meeting

Date: _______________

_____ Intervention Updates

_____ Other documentation forms as necessary.

Action taken: ___ Continue Interventions ___ Modify Interventions

___ Refer to EC ___ Exit Tier III

Follow-up SAT Meeting 2

Date: _______________

_____ Intervention Updates

_____ Other documentation forms as necessary.

Action taken: ___ Continue Interventions ___ Modify Interventions

___ Refer to SPED ___ Exit Tier III

EC Referral

_____ SAT Chairperson submits paperwork to EC – date: ________________