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Name of School

Name of School. Exemplar Application Powerpoint Date: (School Year: YYYY/YYYY) Summer Contact Name : Summer Contact Phone Number:. PBIS Team. Coach, with contact information Team members List with role within PBIS team (Ex: Data analyst)

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Name of School

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  1. Name of School Exemplar Application Powerpoint Date: (School Year: YYYY/YYYY) Summer Contact Name : Summer Contact Phone Number: Revised NC PBIS 10-25-2013

  2. PBIS Team • Coach, with contact information • Team members • List with role within PBIS team (Ex: Data analyst) • List position at school (Ex: 7th grade teacher)

  3. Demographics Name of school, LEA Address Phone Number (Area) ###-#### County Region

  4. Demographics • Grade levels served by school • Student enrollment numbers • Number of faculty/staff members • Ethnicity breakdown

  5. Tier 1 Implementation Components to add: • Systems of practice, organizational structures • Matrix • Acknowledgement systems • Consequence grids • Data to support growth: sustainability, durability • Implementation Inventory results (IIO) for Universals • SET or BSET scores • ODR reports • Possible action items to grow/sustain initiative in this area next year

  6. Tier 2 Implementation Components to add: • Systems of practice, organizational structures • Problem-solving group meetings • Mentoring programs • Check-In Check-Out initiatives • Others • Data to support growth: sustainability, durability • Implementation Inventory (IIO) -results for secondary implementation • ODR reports (or other data) as related to children with chronic behaviors or secondary interventions • Possible action items to grow/sustain initiative in this area next year

  7. Tier 3 Implementation Components to add: • Systems of practice, organizational structures • Teaming/referral flow charts • Problem-solving efforts • Teacher-led behavior support strategies • Student contracting efforts • Data: sustainability, durability • Implementation Inventory results on tertiary implementation • Data collection strategies, summaries for tertiary student data and interventions • Individual student data • Possible action items to grow/sustain initiative in this area next year

  8. Outcome Data: DemonstrateImprovement in BOTH Academic and Behavior Indicators • Academic Data: Achievement data, EOG/EOC scores, math scores, reading scores, etc. • Aggregate data that shows improvement across at least 2 years, including data from the current school year • Behavior Data: Office Discipline Referral, suspension data, expulsion data, EC referral data, climate surveys, ethnicity reports, etc. • Aggregate data that shows improvement across at least 2 years, including data from the current school year • If you see growth over a period of more than two years, but a decline during consecutive years, please show the pattern of growth data in previous years

  9. Outcome Data: DemonstrateImprovement in ONE of the following: • EBS Self-Assessment (pbisapps) • Staff Retention data • Climate surveys • Teacher Working Conditions • YRBS (Youth Risk Behavior Survey) • School-created climate survey • Special Education Referral Information • Attendance rates

  10. Integration of Initiatives (optional) • Responsiveness to Instruction • Character Education • Literacy • Bully prevention programs • Classroom strategies • Problem-Solving strategies (TIPS or other) • Others

  11. District Implementation(optional) • Visibility within LEA, leadership teaming • Political support strategies • Policy change or integration • Training/coaching capacity building • Evaluation/assessment for LEA • Fidelity of implementation

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