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Special Circumstance Instructional Assistance (SCIA) Assessment
Resource Guide
(last edited on 8/24/2018)
This resource provides information on how to systematically conduct a Special
Circumstance Instructional Assistance (SCIA) assessment for a student with a disability.
A recommendation for a SCIA is a significant programmatic decision and one that should
only be made after a comprehensive discussion of other options considered and clear
documentation of as to why those options are not appropriate. An emphasis is placed on
school team collaboration and the use of data collection, checklist, and forms to
determine appropriateness for a SCIA.
Acknowledgements: The South East SELPA recognizes the following individuals for
their feedback and contributions towards the development and revision of this document:
Leo Mapagu, Executive Director, South East SELPA
Helen Huynh, Program Administrator, South East SELPA
Michele Villarreal, Program Administrator, South East SELPA
Wendy Hacke, Program Specialist, Franklin McKinley School District
Carole MacLean, Coordinator, Evergreen Elementary School District
Sandra Quintana, Program Manager, Milpitas Unified School District
Allison Anderson, Program Specialist, Alum Rock Union School District
Katherine Green, Program Specialist, Oak Grove School District
The South East SELPA also recognizes the work of various SELPAs and County Offices
in California, including San Diego County Office of Education and Desert/Mountain
SELPA, in developing and reshaping the SCIA process that assisted the contributing
members in developing this document.
The South East SELPA thanks the Executive Council of Superintendents and the
Operations Committee for the guidance, support, and feedback necessary to update this
document.
1
Rationale
Special Circumstance Instructional Assistance (SCIA) is provided for students with
disabilities when additional support is necessary for the student to meet his or her goals
and objectives. Whenever necessary, additional assistance may be assigned to a school
environment or class. Occasionally, a student may require individual support for a
designated period of time to address a unique need. By law, services to students with
special needs must be delivered in “the least restrictive environment.” When the IEP team
is considering SCIA, all aspects of the student’s program must be considered. A SCIA
request is made only after other documented site interventions and pre-referral activities,
accommodations, and modifications have proven unsuccessful. A student’s educational
program must be carefully evaluated to determine when and where the additional support
is required. Natural supports and existing staff should be used whenever possible to
promote educational benefit in the least restrictive environment. A primary goal for all
students with special needs is to encourage, support, and maximize independence. A SCIA
request should always be considered a time-limited recommendation that must be
periodically reviewed, and specific conditions/goals must be established to fade the use of
a SCIA.
Considerations for Special Circumstance
The general areas to be considered for SCIA are:
1. Health/Personal Care Issues
2. Behavior Support
3. Instruction
4. Least Restrictive Environment
IEP teams should identify the need for related services based on appropriate
documentation and assessment. The SCIA should be carefully monitored and revisited
frequently and reflected in the student’s IEP.
The following statements should be considered for inclusion in the IEP:
a) The related service is necessary for the student to benefit from his/her special
education program;
b) The program modifications or supports for school personnel are necessary to
assist the student; and
c) The related service will assist the student to:
- Advance appropriately toward the annual goals;
- Be involved in and progress in the general curriculum;
- Participate in extracurricular and other nonacademic activities; and
- Be educated and participate with other disabled and non-disabled students.
The IEP team must also address the following components as part of the IEP process:
1) Establish protocol for reviewing and evaluating the necessity of continuing SCIA.
2) Include a statement of the anticipated frequency and duration for the services or
modifications.
3) If it is determined that additional personnel support is required, the IEP team should
periodically review the effectiveness of this additional support. A systematic, written
2
plan needs to address how additional personnel support will be monitored.
4) For services requiring additional personnel support because of a student’s
behavioral difficulties, the student’s IEP needs to include appropriate goals. In
addition, a Behavior Intervention Plan (BIP) should be developed in accordance with
Sections 3001 and 3052 in the Title 5 of the California Code of Regulations (CCR).
The BIP needs to include a provision describing how and when support, including
personnel, will be utilized to implement the plan, and when the plan will be reviewed
and modified.
5) When determining the need for additional personnel support due to an instructional
need, the IEP team must utilize appropriate assessment information to support this
recommendation. The written plan must be developed by a general and/or special
education teacher specifying how the additional personnel will be utilized to support
the teacher in implementing the student’s goals and objectives and what attempts
will be made to transition other available classroom resources and supports.
6) When additional support necessary due to a medical need, a specialized health care
plan will need to be developed.
7) When SCIA is considered for a specific student, a LEA representative shall be
required to participate in the decision-making process of the IEP meeting.
Procedures
Prior to a SCIA assessment, the IEP team should determine if all available natural
supports, accommodations, and modifications have been in place with fidelity. A request
should only be made after other site interventions have proven to be ineffective.
Whenever possible, additional assistance is assigned to a school environment, class, or
case manager. Occasionally, a student may require individual support for a designated
period of time to address a unique need. Below are nine steps to completing the SCIA
assessment process.
Step 1: Pre-referral Activities
Use the SCIA rubric and SCIA Independence Continuum to determine if student is at an
independence level 1 or 2. Refer to the pre-referral activities checklist to determine if
current activities, accommodations, and modifications related to Least Restrictive
Environment, Health, Instruction, and Behavior have been implemented with fidelity and
without success as indicated by data.
Step 2: Referral for SCIA
If the pre-referral activities have been implemented and deemed unsuccessful based on
data, and students receive a SCIA rubric and SCIA Independence Continuum score of 3
or 4, submit the SCIA request cover page along with the SCIA referral form with
supporting documentation. The district will decide to proceed with assessment or provide
alternatives.
Step 3: Assessment Plan
If the district moves forward with a SCIA assessment, parent permission must be
obtained in writing within 15 days.
Step 4: Parent/Teacher/Student Interview
Interview parents and teachers to identify specific areas of concern. Interview the student
as appropriate based on age and level of self-awareness.
3
Step 5: Environmental Observation/Student Observation
SCIA assessor will observe the natural environment to collect data by examining
strategies, materials, modifications, and/or accommodations currently in place to assist
the student toward achieving goals and objectives. SCIA assessor will observe the
student’s level of response to the current existing supports.
Step 6: SCIA Rubric
Analyze data collected and determine student’s level of independence in the appropriate
areas, factoring in time of day, number or prompts needed, and the amount of adult
support needed to complete demands when compared to other students in the setting.
Step 7: Develop SCIA Evaluation Report
Organize and summarize assessment findings in a written report. The report should
include reason for referral, interview information, observation data, and
recommendations based on all the relevant information obtained.
Step 8: Convene IEP Meeting to Discuss Evaluation Results
Within 60 days following the receipt of parent consent to evaluate for SCIA, an IEP
meeting shall be convened to review the results of the evaluation and recommendations.
Step 9: SCIA Independence/Fade Plan
If the IEP team determines a need for SCIA, it is written on the IEP with specific goals,
monitoring strategies, fading strategies, and review dates. Regardless of the circumstance
that may indicate the need for support, it is imperative for every IEP to address the skills
that will be taught for SCIA to be faded. The level of support required for the student to
advance appropriately toward annual goals need to be defined, including criteria and
possible timeline for phasing out SCIA support. If a Behavior Intervention Plan is part of
the recommendation, the IEP team must also complete an Independence/Fade Plan in
conjunction with the SCIA Independence/Fade Plan and Behavior Intervention Plan
Checklist. IEP teams need to also complete the Review of Independence/Fade Plan to
determine continued need for SCIA by scheduling future meetings.
South East SELPA SCIA Forms
Form 1: Pre-Referral Flow Chart (p. 7)
This flow chart assists with determining if there is a need to complete the SCIA process,
or if other interventions need to be considered for implementation (e.g., Pre-referral
activities/accommodations/modifications, Behavior Intervention Plan, etc.).
Form 2: Pre-Referral Rubric (p. 8)
Use this form to determine the student’s current level of need.
Form 3: Special Circumstance Instructional Assistance Independence Continuum
(p. 9)
Use this form in conjunction with the pre-referral rubric to determine student’s current
level of independence.
4
Form 4: Pre-Referral Activities/Modifications/Accommodations Checklist (p. 10)
Use this form to determine if activities, modifications, and accommodations have been
consistently implemented or if there are any missing supports related to Least Restrictive
Environment, Health, Instruction, and Behavior.
Form 5: Special Circumstance Instructional Assistance Request Cover Page
(p. 11-12)
This form serves as a planning guide for the entire SCIA process and must be completed
by the IEP Case Manager/Psychologist and updated frequently.
Form 6: Special Circumstance Instructional Assistance Referral (p. 13)
This form is completed by the evaluation team/referring staff. Required documentation of
previous and current interventions, as well as the purpose/need for the SCIA must be
clearly noted with data demonstrating need.
Form 7: Classroom Adaptations and Modifications Checklist (p. 14)
This form identifies the various adaptions and modifications that are currently being
implemented in the classroom. This can be completed by the classroom teacher or a
member of the evaluation team and submitted with the Special Circumstance Instructional
Assistance Referral packet.
Form 8: Parent Interview (p. 15)
This form is used by the assessor to incorporate parent input and obtain information
regarding the student’s level of independence and potential need for support in specific
areas.
Form 9: Teacher Interview (p. 16)
This form is used by the assessor to incorporate teacher input and obtain information
regarding the student’s level of independence and potential need for support in specific
areas.
Form 10: Student Interview (p. 17)
This form is used by the assessor to incorporate student input and obtain information (as
appropriate) regarding the student’s level of independence and potential need for support
in specific areas.
Form 11: Special Circumstance Instructional Assistance Environmental Observation
Evaluation (p. 18-20)
This form assists with identifying needs relating to classroom structure, curriculum,
classroom environment and classroom team planning and preparation.
Form 12: Special Circumstance Instructional Assistant Assessment Classroom
Observation of Student (p. 21)
This form assists with determining specific times and/or activities when support may be
needed.
Form 13: Special Circumstance Instructional Assistance Rubric (p. 22)
This rubric should be filled out by the classroom teacher and include additional
documentation identifying the current level of support needed by the student.
5
Form 14: Special Circumstance Instructional Assistance Behavior Intervention Plan
(p. 23-24)
This form is completed when students may need SCIA support due to behavior(s).
Form 15: Special Circumstance Instructional Assistance Independence Behavior
Intervention Plan Checklist (p. 25)
This form must be completed when the SCIA assessment is requested due to behavioral
issues and is aligned to support the student’s current Behavior Intervention Plan.
Form 16: Special Circumstance Instructional Assistance Independence Fade Plan
(p. 26)
An independent/fade plan (as appropriate) must be included in the IEP to determine how
the SCIA will be faded. The plan should include goals, timelines, progress monitoring
methods, generalization strategies, and specific criteria for fading SCIA support.
Form 17: Review of Independence/Fade Plan to Determine Continued Need for
Special Circumstance Instructional Assistance (p. 27)
Once a student has been approved for a SCIA and one has been implemented, the
evaluation team should continue to observe the student to determine appropriateness and
monitor student progress. This form should be completed and reviewed at least every 3-6
months to determine the effectiveness of the SCIA support and/or continued need.
Appendix
Form A: Sample Special Circumstance Instructional Assistance Assessment Evaluation
Report (p. 28-30)
Form B: Sample Special Circumstance Instructional Assistance Behavior Intervention
Plan (p. 31-33)
6
Form 1 - Pre-Referral Process Flow Chart
Assess classroom activities,
accommodations and modification and
the need for additional staff training.
Adjustments and/or trainings are
successful.
Develop or revise behavior intervention
plan (BIP), if applicable.
Adjustments are successful.
Adjustments are not successful.
Complete SCIA Request.
Adjustments and additional trainings
are not successful.
7
Complete Pre-Referral Rubric and
Checklist. Implement activities,
accommodations, and modifications
that are currently missing.
Confirm if the IEP/BIP has goals
developed in the area(s) of concern.
Yes, but they are not being met.
If not, STOP. Develop IEP goals to
address the area of concern.
Implement classroom activities,
accommodations, and modification if
SCIA Pre-referral rubric scores are
within the 1 to 2 range.
Teacher, Parent, and/or IEP Team
expresses concern regarding a need
for additional support
Form 2 - Special Circumstance Instructional Assistance Pre-Referral Rubric
Student Name: ________________________ DOB: ________________ Teacher: __________________ Date: _______________
School: ________________________ Rubric Completed by: ____________________
Health/Personal Care
Behavior
Instruction
Least Restrictive Environment
0
General good health and developmentally
appropriate personal care skills. Health care
procedures and/or personal care interventions are
not typically required. Independently maintains all
age appropriate personal care and/or medical needs.
0
Exhibits age or developmentally appropriate
behavior. Interventions are not typically
required. Follows directions and handles
redirection appropriately. Student
independently addresses own behavior needs
and required supports are similar to those of
same-aged peers.
0
Independently participates fully in individual,
small group, and whole class instruction.
Accommodations and modifications beyond
those routinely provided for the class are not
required.
0
Developed IEP goals can be met through partial or full
inclusion in general education. Participates in some core
curriculum with the general education setting and requires a
few accommodations. Independently goes to and
successfully participates in assigned general education
classes.
1
Mild or occasional health concerns. Allergies or
other chronic health concerns. No specialized
health care procedure. Medications administered
takes less than 10 minutes per day. Needs
reminders to complete personal care activities.
Requires support with 0-25% of their age
appropriate personal care and/or medical needs.
1
Mild or occasional behavior incidents. Follows
adult directions but occasional requires
additional encouragement and prompts about 0-
25% of the day. Occasional difficulties with
peers and adults, but behaviors are not typically
considered dangerous.
1
Participates in individuals, small group, and
whole class instruction at instructional level,
but may require additional prompting or
reinforcement 0-25% of the time. Requires
reminders to stay on task, follow directions,
and to remain engaged in learning. Specialized
instructional strategies are not required.
1
Developed IEP goals can be met through partial or full
inclusion in general education with the use of some
accommodations and/or modifications. Needs occasional
prompts to participate in general education and/or interact
with peers 0-25% of the time. Requires some additional
support to finish work and be responsible.
2
Chronic health issues (ear infections, ADD, bee
sting allergy). Generic specialized health care
procedure and takes medication. Intervention for
10-15 minutes daily. Requires reminders and
occasional additional prompts or limited hands-on
assistance for washing hands, using the bathroom,
wiping mouth, etc. Occasional toileting accidents.
Requires support with 26-50% of their age
appropriate personal care and/or medical needs.
2
Moderate level of behavior incidents, has
problems following directions and behaving
appropriately. Adult intervention is required
daily, but can be managed adequately with a
classroom management plan. May require
behavior intervention plan implementation, and
adult support 26-50% of the day.
2
Cannot always participate in whole class
instruction without modifications. Requires
smaller groups and frequent verbal prompts,
cues, or reinforcement. On task about 50% of
the time with support. Requires frequent verbal
prompts to follow directions 26-50% of the
time. Specialized instructional strategies are
not required.
2
Developed IEP goals can be met through partial or full
inclusion in general education with use of accommodations
and/or modifications. Participates with visual supervision
and occasional verbal prompts. Requires visual shadowing
to get to class. Requires adult shadowing for short period of
time daily. Requires prompts to participate in general
education and/or interact with peers 26-50% of the time.
3
*
Very specialized healthcare procedure and
medication. Limited mobility or physical
limitations requiring assistance (stander, walker,
gait trainer, or wheelchair). Special food prep or
feeding. Health related interventions 15 to 45
minutes daily. Frequent physical prompts to
participate in personal care. Requires toilet
schedule, training, direct help, diapering, etc.
Requires support with 51-75% of their age
appropriate personal care and/or medical needs.
3
*
Serious level of behavioral incidents. Requires
routine adult monitoring and intervention to
prevent escalation into dangerous situations.
Defiant and prone to physical aggression.
Requires a behavioral intervention plan and
behavior goals and objectives in the IEP. May
require adult support 51-75% of the day to
address behavior needs described in BIP.
3
*
Participation in individual, small group, and
whole class instruction requires close adult
proximity and monitoring about 51-75% of the
time 2daily. Requires low student staff ratio
and prompts including physical assistance to
stay on task. Primarily complies only with 1:1
directions and monitoring. Requires highly
specialized strategies that require specific
teacher training.
3
*
Developed IEP goals can be met through partial or full
inclusion in the general education with frequent use of
accommodations and/or modification. Requires adult to
monitor success in accessing curriculum. Participates with
direct instructional and behavioral support. Requires direct
supervision going to and from class. Requires low student
staff ratio and multiple prompts, including physical
assistance to stay on task 51-75% of the time.
4
*
Specialized healthcare procedures requiring care by
specially trained adult (G-tube, tracheotomy,
cauterization). Takes medication, requires
positioning by bracing multiple times daily. Health
related intervention and direct 1:1 assistance at
least 45 minutes daily. Direct assistance with most
personal care. Requires two-person lift. Direct
support required with at least 76% or all personal
care and medical needs.
4
*
Severe level of behavioral incidents. Behavior
problems with potential for injury to self and
others, runs away, and aggressive daily.
Analysis of behavior has been completed and
the student has a well-developed BIP. Requires
constant and immediate supervision and
intervention from a specially trained adult to
prevent escalation into dangerous situations.
Requires 76%-100% adult support daily.
Participation in any setting requires constant
1:1 support. Requires verbal and physical
prompting to stay on-task and follow directions
76% or more of the time. Regularly requires
specific 1:1 instructional strategies.
4
*
IEP goals can be met through partial or full inclusion in
general education with extensive use of accommodations
and/or modifications. Requires constant adult supervision to
access curriculum. Always requires 1:1 staff in close
proximity for direct instruction, safety, mobility, or
behavioral monitoring. Requires 1:1 assistance to go to and
from class. Requires verbal and physical prompting to stay
on-task and follow directions 76% or more of the time.
*Complete and implement missing activities, accommodations, and modifications for scores within the 1-2 range. Proceed with SCIA referral process for scores within the 3-4 range after implementing missing
activities, accommodations, and modifications.
8
Form 3 - Special Circumstance Instructional Assistance Independence Continuum
Level 0 - Independent
Level 1 – Independent with extra
teacher awareness
Level 2 – Mostly Independent
Level 3 – Partially Independent
Level 4 – Not Independent
-Responds to natural
environmental supports as other
peers
-Gets along with others/seeks out
friends/socializes at level of peers
-Few if any accommodations are
needed
-Stays on task and requires the
same amount of prompting as
others
-Student can request for help
-Proximity to student is average
compared to others
-Maintains all age-appropriate
personal needs
-Responds to natural environmental
supports with additional
accommodations provided by teacher
-Peers can be used as additional
support
-Some support to understand class
assignments
-Follows adult direction and may
need some prompts and reminders to
remain on task a little more than
others
-Proximity to student is average
compared to others with some
additional checking in
-May require mild healthcare or some
reminders to maintain age appropriate
personal needs
-Needs assistance or further teaching
in following the natural cues in the
environment
-Requires additional behavior
support than others (progress report,
behavior charts, etc.)
-Difficulty following directions and
behaving appropriately, but
responds to specific strategies
outlines on the accommodations
page of IEP or in a Behavior
Intervention Plan
-Requires some assistance to support
critical parts of the day. Proximity
closer than others during these times
-Requires more direct
prompting/reminders than expected
in the classroom
-Requires specific accommodations
or modifications to some tasks and
assignments
-Social skills may need some
facilitating
-Mild health related issues addressed
by the school nurse
-Serious behavior problems daily –
defiant and/or prone to physical
aggression (may be harmful to self
or others)
-FBA completed and requires
Behavior Intervention Plan,
including behavior goals on IEP
with close supervision of plan
implementation
-Has difficulty participating in
groups
-Requires low student/staff ratio
and needs close adult proximity to
stay on task (2-3 feet)
-Complies mainly with 1:1
directions
-Signing 50-80% of the time
-Requires a structured adult
facilitated program for
socialization
-May have specialized health
issues or medications; limited
mobility; feeding issues; and/or
frequent physical prompts and
directions for personal care –
requires assistance with the
bathroom for basic care
-Does not or cannot participate
without 1:1 support
-Requires constant
attention/prompting to complete
tasks
-Needs full or partial physical
prompts
-Proximity of student – within one
foot
-Serious behavior problems – FBA
completed and requires Behavior
Intervention Plan
-Requires specially trained
behavior staff
-Cognitive abilities and skills
require significant modifications to
curriculum
-May need signing 100% of the
time
-Requires direct supervision at all
times
-Rarely or does not interact with
others and needs a structured adult
facilitated program for social skills
and communication
-Intensive health needs requiring
1:1 personal care
*Complete and implement missing activities, accommodations, and modifications for scores within the 1-2 range. Proceed with SCIA referral process for scores within the 3-4 range after implementing missing
activities, accommodations, and modifications.
9
Form 4 - Pre-Referral Activities, Accommodations, and Modifications Checklist
Environment
Assignment
Request for Assistance
☐
Clarify rules
☐Positive interaction
☐Procedures are taught/established
☐Active rule teaching
☐Change seating
☐Change groups
☐Reduce distractions
☐Special study area
☐Break area
☐Peer supports
☐Posted visual schedule
☐Visual supports
☐Use of prompts
☐Use of timer
☐Active engagement/supervision
☐Staff proximity
☐Reduce distractions
☐Rearrange physical environment
☐Materials/supplies clearly labeled
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
☐
Shorten
☐Leveled/matched to student’s instructional level
☐Individual contracts
☐Extended time
☐Daily assignment book
☐Check-in/check-out
☐Checklist/task analysis
☐Start buddy
☐Provision of choice
☐Output Differentiation
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
☐
Conference with parents
☐Collaborate with community agencies/professionals
☐Confer with other school staff
☐Additional staff training
☐Behavior Intervention Plan
☐Classroom team meeting
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
Communication
Curriculum/Materials
Teaching Techniques
☐
Access to communication system
☐Predictable means of communication
☐Staff prompts communication
☐Staff encourages communication
☐Classroom community circle/meeting
☐Home/school communication (log/email)
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
☐
Change instructional materials
☐High-interest reading/instructional materials
☐Use of computer
☐Calculator
☐Books on tape
☐Copied notes
☐Learning games
☐Assistive devices
☐Technology Devices
☐Reinforcers
☐Behavior charting
☐Reinforcement schedule
☐Lesson plan clearly written
☐Manipulatives
☐Realia
☐IEP objectives address deficit areas
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
☐
Consistent rules & consequences across
staff
☐Teach study skills
☐Teach social skills
☐Teach new behaviors
☐Strategies instruction
☐Reteach (instruction/assignment)
☐Verbal praise
☐Frequent feedback
☐Frequent check-in
☐Eye contact
☐Use of multiple modalities (visual, aids,
hands-on)
☐Small group instruction
☐Centers
☐Cross-age tutoring
☐Pre-correction
☐Preview assignments/materials
☐Use of prior knowledge
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
10
Form 5 - Special Circumstance Instructional Assistance Request Cover Page
Student:
Placement:
Date:
Age:
Sp Ed Teacher:
Primary/Secondary Disability:
DOB:
Gen Ed Teacher:
Current Setting:
School:
Site Administrator:
Contact Phone:
Grade:
Other:
School Psychologist:
I. Interventions Previously Implemented
To Be Completed by IEP Case Manager/Psychologist Prior to Referral
☐ Prior to considering a SCIA referral, team must exhaust all existing natural _______
supports contained in the IEP and Behavior Intervention Plan (if applicable).
Date/Initials
☐ Complete pre-referral activities and implement necessary/missing components. _______
Date/Initials
☐ Gather behavioral data (data collection on frequency, duration, and _______
and severity).
Date/Initials
☐ Review BIP implementation data, if appropriate. _______
☐ BIP – Data and strategies used to increase replacement behaviors.
Date/Initials
Implementation for at least three months with revisions, as needed.
☐ Gather information from other records, as appropriate. _______
☐ Academic progress/Interventions and behavioral data
Date/Initials
☐ Student’s schedule (including grades and attendance)
☐ Psycho-educational reports
☐ Discipline referral information
☐ Health records
☐ Communication competency
☐ Use of AT/AAC
II. Referral Process
☐ Complete SCIA referral _______
Date/Initials
☐ Complete Review of BIP and progress on behavior goals _______
Date/Initials
III. Assessment Process
☐ Complete SCIA Parent Interview(s) _______
Date/Initials
☐ Complete SCIA Teacher Interview(s) _______
Date/Initials
☐ Complete SCIA Student Interview, as appropriate _______
Date/Initials
☐ Complete SCIA Observation: Environmental considerations _______
Date/Initials
☐ Complete SCIA classroom observation of student _______
Date/Initials
☐ Complete SCIA rubric _______
11
Date/Initials
☐ Complete additional Evaluation(s) per Assessment Plan _______
Date/Initials
☐ Develop SCIA Evaluation Report and Independence/Fade Plan _______
Date/Initials
IV. IEP Process
☐ Hold IEP meeting to review results of evaluation _______
Date/Initials
☐ If SCIA support IS NOT recommended _______
☐ Specify natural supports, accommodations, and/or modifications
Date/Initials
that are effective in student’s IEP
☐ Add IEP goals and objectives, if appropriate
☐ Specify natural supports, accommodations, and/or modifications
that are effective in student’s IEP
☐ If SCIA support IS recommended _______
☐ Identify IEP Goals and Objectives to be supported by SCIA support
Date/Initials
☐ Complete IEP Special Factors page regarding Behavior, if appropriate
☐ Complete IEP Services page: under Supplementary Aids, Services and Other
Supports for School Personnel Check: Intensive Individual Services
Include start/end date, frequency and duration, and location of SCIA support
☐ Review proposed Independence/Fade Plan and type of documentation that will
be collected
☐ Set review date within 3 to 6 months to assess continued need of SCIA support
☐ Complete and send Prior Written Notice to parents
V. SCIA Review
☐ Select IEP date to review progress on independence goals _______
Date/Initials
☐ Conduct on-going observation, necessary interview, and progress towards _______
independence
Date/Initials
☐ Review BIP – Analyze and revise, as needed _______
Date/Initials
☐ Complete SCIA Review to Determine Continued Need for SCIA Supports _______
Date/Initials
☐ Review Independence/Fade Plan and documentation with parent and _______
IEP team
Date/Initials
12
Form 6 - Special Circumstance Instructional Assistance Referral
Student:
Placement:
Date:
Age:
Sp Ed Teacher:
Primary/Secondary Disability:
DOB:
Gen Ed Teacher:
Current Setting:
School:
Site Administrator:
Contact Phone:
Grade:
Other:
School Psychologist:
Attach the following information:
☐ IEP goals with the progress toward the goals noted specific to areas of needed support
☐ Student’s BIP (if available)
☐ Behavioral documentation of noted areas of concern (data collection on frequency, duration, and severity of behavior, logs, charts, narratives)
☐ Accommodations/modifications Checklist
☐ Student’s daily schedule including related services
☐
Health records (if necessary)
*Check the areas of intensive need that might indicate SCIA support and indicate the time/period where support may be needed
Health/Personal Care
☐ Health Plan ☐ Full toilet care
☐ G-Tube ☐ Diapers
☐ Medication ☐ Toilet training
☐ Suctioning ☐ Dressing
☐ Monitoring ☐ Food Prep
Health Status ☐ Hygiene
☐ Eating ☐ Mobility
☐ Other:
Time/Period:___________________
Behavior
☐ Participation in BIP
☐ Aggressive
☐ Assaultive
☐ Non-compliant
☐ Over-active
☐ Runs away
☐ Disruptive
classroom
behavior
☐ Other:
Time/Period:_________________
Instruction
☐ Physical assistance
☐ Constant verbal prompts
☐ TEACHH/DTT
☐ Assistive Technology
☐ PECS
☐ Other:
Time/Period:_________________
Least Restrictive Environment
☐ Direct instruction
☐ Physical support/positioning
☐ Safety/close supervision (80%+)
☐ Other:
Time/Period:________________________
Previous Interventions and Results: Describe interventions used to support the student in each of the areas marked above. Provide data (include frequency, duration,
and location) that documents the success or failure of interventions. Attach additional pages as necessary.
How are existing staff in your classroom or on your site utilized? Student/Staff Ratio:__________
Other specific classroom and/or unique needs:
Request Made by:
☐
Case Manager
☐
Parent/Guardian
☐
Teacher
☐
Other:
Staff Making Referral (print name and sign): ____________________________________________ Date: _________________________
School Site Administrator (print name and sign): _________________________________________ Date: _________________________
13
Form 7 – Classroom Adaptations and Modifications Checklist
Environment
Assignment
Request for Assistance
☐
Clarify rules
☐Positive interaction
☐Procedures are taught/established
☐Active rule teaching
☐Change seating
☐Change groups
☐Reduce distractions
☐Special study area
☐Break area
☐Peer supports
☐Posted visual schedule
☐Visual supports
☐Use of prompts
☐Use of timer
☐Active engagement/supervision
☐Staff proximity
☐Reduce distractions
☐Rearrange physical environment
☐Materials/supplies clearly labeled
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
☐
Shorten
☐Leveled/matched to student’s instructional level
☐Individual contracts
☐Extended time
☐Daily assignment book
☐Check-in/check-out
☐Checklist/task analysis
☐Start buddy
☐Provision of choice
☐Output Differentiation
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
☐
Conference with parents
☐Collaborate with community agencies/professionals
☐Confer with other school staff
☐Additional staff training
☐Behavior Intervention Plan
☐Classroom team meeting
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
Communication
Curriculum/Materials
Teaching Techniques
☐
Access to communication system
☐Predictable means of communication
☐Staff prompts communication
☐Staff encourages communication
☐Classroom community circle/meeting
☐Home/school communication (log/email)
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
☐
Change instructional materials
☐High-interest reading/instructional materials
☐Use of computer
☐Calculator
☐Books on tape
☐Copied notes
☐Learning games
☐Assistive devices
☐Technology Devices
☐Reinforcers
☐Behavior charting
☐Reinforcement schedule
☐Lesson plan clearly written
☐Manipulatives
☐Realia
☐IEP objectives address deficit areas
☐ Other: ____________________
☐ Other: ____________________
☐ Other: ____________________
☐
Consistent rules & consequences across
staff
☐Teach study skills
☐Teach social skills
☐Teach new behaviors
☐Strategies instruction
☐Reteach (instruction/assignment)
☐Verbal praise
☐Frequent feedback
☐Frequent check-in
☐Eye contact
☐Use of multiple modalities (visual, aids,
hands-on)
☐Small group instruction
☐Centers
☐Cross-age tutoring
☐Pre-correction
☐Preview assignments/materials
☐Use of prior knowledge
☐ Other: ____________________
☐ Other: ____________________
☐
Other: ____________________
14
Form 8 - Special Circumstance Instructional Assistance Assessment Parent Interview
Domain
Suggested Questions
Notes
Health and Personal Care
1) Based on your experience in the home,
which personal care activities would you
expect your child to complete independently at
school?
2) Which, if any, do you believe he or she may
need adult support with at school?
Behavior
1) Based on your experience at home, how
independent is your child in
a) Staying in a designated area during
activities, such as meal time, homework time,
or TV time?
b) Being mindful of safety during activities,
such as playing with peers or crossing the
street?
c) Completing tasks, such as chores or
homework?
2) What areas are difficult for your child?
3) During which activities doe these
difficulties occur?
Instruction
1) What special education service and/or other
assistance does your child currently receive?
2) When is your child successful during his/her
school day?
What is working?
3) What other school programs, support from
other staff, or students does your child benefit
from?
General Questions
1) During which activities is your child most
independent and requiring least amount of
support?
2) During which activities is your child least
independent and requiring most amount of
support?
3) What do you see as next steps for your
child, such as, area that you would like to see
improve?
4) Do you have any safety concerns?
Form 9 - Special Circumstance Instructional Assistance Assessment
Teacher Interview
Domain
Suggested Questions
Notes
Health and Personal Care
1) What time of day/content areas have you
observed the student needing more personal
care or medically related activities relative to
his/her peers?
Behavior
1) What time of day/content areas have you
observed the student need more adult support
than his/her peers to demonstrate appropriate
behavior? Please be specific.
Instruction
1) Which content area do you feel the student
is most independent in?
In this content area, approximately how many
more prompts does the student need than
his/her peers to participate?
2) Which content area do you feel the student
is least independent in?
In this content area, approximately how many
more prompts does the student need than
his/her peers to participate?
3) What assistance does the student currently
receive?
4) What skills would you like the student to
develop to be more independent?
5) When is the student successful during
his/her school day? What is working?
Least Restrictive Environment
1) If the student participates in general
education, about what percentage of the time
does the student require adult support to access
the curriculum?
2) If the student participates in general
education, about what percentage of the time
does the student require adult support to
interact socially with peers?
General Questions
1) Is there anything else you would like to
share?
15
1
6
Domain
Suggested Questions
Notes
Behavior
1) When do you have problems during your
school day?
Instruction
1) What do you like about school?
2) When are you successful?
3) How do school staff members help you
during the day?
4) Who else helps you during school?
5) What programs do you participate in that
help you?
6) What are some things you would like to
learn to help you be more independent?
General Questions
1) Is there anything else you would like us to
know about you?
17
Form 10- Special Circumstances Instructional Assistance
Student Interview
Form 11 - Special Circumstance Instructional Assistance Environmental Observation
*Please review visual and physical structure of the classroom, curriculum instruction, data collection, and planning.
Student:
DOB:
School:
Grade:
Observation Setting:
Date: Start/End Times: /
Observer Name:
Observer Position:
Number of Students in Class:
Number of Adults in Class:
A. Classroom
1. Is individual student/classroom schedule and procedures accessible, if needed? ☐Yes ☐No
A. Student use of the schedule:
☐ Student carries schedule
☐ Student goes to schedule board
☐ Student uses transition cards
☐ Teachers carries and shows the schedul
e
☐
Schedule not used at all
☐ Other: ____________________________
B. Levels of prompt needed for student to follow schedule:
☐ Independent
☐ Indirect verbal or gestural prompt
☐ Physical prompt
☐ Direct Verbal prompt
☐ Other
2. Is the entire daily schedule posted on the board and reviewed often? ☐Yes ☐No
Describe:
2a. Is transition between activities quick and smooth? ☐Yes ☐No
Explain:
2b. Does teacher provide ample warning to students that a change is going to happen? ☐Yes ☐No
Explain:
3. Is room organized with work areas defined and materials readily available for instruction?☐Yes ☐No
Describe:
4. D
o students follow established classroom procedures and routines? ☐Yes ☐No
Describe:
B. Curriculum and instructional Planning
1. Check the curriculum domains included in student’s program:
☐
Academics
☐
Motor skills/mobility
☐
Behavior
☐
Pre-vocational/vocational
☐
Communication
☐
Self-care
☐
Functional Academics
☐
Social Skills
☐
Health
18
2. What curriculum accommodations and/or modifications are being used? How long have they been in use?
3. List equipment or devices used that may relate to the need for assistance (e.g. low incidence equipment, assistive
technology devices):
4 Are materials and activities age-appropriate? ☐Yes ☐No
5. Are materials and activities instructionally appropriate? ☐Yes ☐No
6. Describe lessons observed:
C. Classroom Behavior and Safety
1. Describe the behavior management system in the classroom including positive reinforcers and consequences. Is
it appropriate for the student or does it need to be modified?
2. Are specific positive behavior supports utilized for the student? ☐Yes ☐No
Describe:
3. Is there appropriate safety equipment in place? ☐Yes ☐No
4. Are appropriate safety and medical procedures being used? ☐Yes ☐No
5. Does it appear appropriate training has been provided to staff? ☐Yes ☐No
Comments:
D. Describe the student’s behavior in independent activities.
1. Describe the student’s interaction with peers
2. Describe the student’s interactions with non-classroom staff in a less structured environment?
3. What activities does the student choose during breaks?
4. What problems are evident?
19
E. Describe the school day and assistance now provided (Include natural supports such as peers and
school staff, volunteers, etc.).
F. What assistance currently exists?
☐Behavior management?
☐Medical assistance
☐Curriculum adaptation and preparation
☐Supervision
☐Instruction- individual
☐Instruction- group
☐Other:________________________
G. Can current conditions be modified to meet the student’s goals and objectives and/or personal care
needs?
☐
Yes ☐No Explain:
H. Are other types of assistance needed? Describe:
I. Current Data Systems and Collection of Data
1. Has data been collected on student performance? ☐Yes ☐No
2. How often is data collected? ☐Daily ☐Bi-weekly ☐Weekly ☐Monthly
3. How is data summarized? ☐Graphed ☐Written narrative ☐Other:_________________
4. What evidence is there for accommodations and/or modifications being used?
J. Are there any other issues that need to be addressed, and/or any additional comments?
20
Form 12 - Special Circumstance Instructional Assistance Assessment
Classroom Observation of Student
Focus behavior(s): _________________________________________________________________________________
Observed By:_____________________________ Position:_______________________________
Date:__________________ Time (start/end):________________
Time/Subject Matter
Observation Notes
Example:
7:30-8:00 Arrive and breakfast
*Observed a student to teacher ratio of 10:2 for bus and 5:1 for
breakfast
Example: Student walks hand in hand with an aide from the bus
to the breakfast tables. He walks at a slower pace and required
10 prompts and continuous monitoring to continue along the
path. He was given maximum assistance to eat. While the other
aide was with a small group, student was in a group of about 5
students. When the aide turned to assist another student in the
group, he would attempt to stand and walk away.
Requires 2:1 to walk from bus and 1:1 for feeding.
Date/Time:
E
nvironment:
Date/Time:
E
nvironment:
Date/Time:
E
nvironment:
Date/Time:
E
nvironment:
Date/Time:
Environment:
Date/Time:
E
nvironment:
Date/Time:
Environment:
Date/Time:
E
nvironment:
Date/Time:
Environment:
Date/Time:
E
nvironment:
*Circle the time of day where support is needed and analyze intensity of support needed beyond naturally embedded supports
(i.e., specific time of the day, activities, routines, etc.).
21
Form 13 - Special Circumstance Instructional Assistance Rubric
Student Name: ________________________ DOB: ________________ Teacher: __________________ Date: _______________
Sc
hool: ________________________ Rubric Completed by: ____________________
Health/Personal Care
Behavior
Instruction
Least Restrictive Environment
0
General good health and developmentally
appropriate personal care skills. Health care
procedures and/or personal care interventions are
not typically required. Independently maintains all
age appropriate personal care and/or medical needs.
0
Exhibits age or developmentally appropriate
behavior. Interventions are not typically
required. Follows directions and handles
redirection appropriately. Student
independently addresses own behavior needs
and required supports are similar to those of
same-aged peers.
0
Independently participates fully in individual,
small group, and whole class instruction.
Accommodations and modifications beyond
those routinely provided for the class are not
required.
0
Developed IEP goals can be met through partial or
full inclusion in general education. Participates in
some core curriculum with the general education
setting and requires a few accommodations.
Independently goes to and successfully participates in
assigned general education classes.
1
Mild or occasional health concerns. Allergies or
other chronic health concerns. No specialized
health care procedure. Medications administered
takes less than 10 minutes per day. Needs
reminders to complete personal care activities.
Requires support with 0-25% of their age
appropriate personal care and/or medical needs.
1
Mild or occasional behavior incidents. Follows
adult directions but occasional requires
additional encouragement and prompts about 0-
25% of the day. Occasional difficulties with
peers and adults, but behaviors are not typically
considered dangerous.
1
Participates in individuals, small group, and
whole class instruction at instructional level,
but may require additional prompting or
reinforcement 0-25% of the time. Requires
reminders to stay on task, follow directions,
and to remain engaged in learning. Specialized
instructional strategies are not required.
1
Developed IEP goals can be met through partial or
full inclusion in general education with the use of
some accommodations and/or modifications. Needs
occasional prompts to participate in general education
and/or interact with peers 0-25% of the time.
Requires some additional support to finish work and
be responsible.
2
Chronic health issues (ear infections, ADD, bee
sting allergy). Generic specialized health care
procedure and takes medication. Intervention for
10-15 minutes daily. Requires reminders and
occasional additional prompts or limited hands-on
assistance for washing hands, using the bathroom,
wiping mouth, etc. Occasional toileting accidents.
Requires support with 26-50% of their age
appropriate personal care and/or medical needs.
2
Moderate level of behavior incidents, has
problems following directions and behaving
appropriately. Adult intervention is required
daily, but can be managed adequately with a
classroom management plan. May require
behavior intervention plan implementation, and
adult support 26-50% of the day.
2
Cannot always participate in whole class
instruction without modifications. Requires
smaller groups and frequent verbal prompts,
cues, or reinforcement. On task about 50% of
the time with support. Requires frequent verbal
prompts to follow directions 26-50% of the
time. Specialized instructional strategies are
not required.
2
Developed IEP goals can be met through partial or
full inclusion in general education with use of
accommodations and/or modifications. Participates
with visual supervision and occasional verbal
prompts. Requires visual shadowing to get to class.
Requires adult shadowing for short period of time
daily. Requires prompts to participate in general
education and/or interact with peers 26-50% of the
time.
3
*
Very specialized healthcare procedure and
medication. Limited mobility or physical
limitations requiring assistance (stander, walker,
gait trainer, or wheelchair). Special food prep or
feeding. Health related interventions 15 to 45
minutes daily. Frequent physical prompts to
participate in personal care. Requires toilet
schedule, training, direct help, diapering, etc.
Requires support with 51-75% of their age
appropriate personal care and/or medical needs.
3
*
Serious level of behavioral incidents. Requires
routine adult monitoring and intervention to
prevent escalation into dangerous situations.
Defiant and prone to physical aggression.
Requires a behavioral intervention plan and
behavior goals and objectives in the IEP. May
require adult support 51-75% of the day to
address behavior needs described in BIP.
3
*
Participation in individual, small group, and
whole class instruction requires close adult
proximity and monitoring about 51-75% of the
time 2daily. Requires low student staff ratio
and prompts including physical assistance to
stay on task. Primarily complies only with 1:1
directions and monitoring. Requires highly
specialized strategies that require specific
teacher training.
3
*
Developed IEP goals can be met through partial or
full inclusion in the general education with frequent
use of accommodations and/or modification. Requires
adult to monitor success in accessing curriculum.
Participates with direct instructional and behavioral
support. Requires direct supervision going to and
from class. Requires low student staff ratio and
multiple prompts, including physical assistance to
stay on task 51-75% of the time.
4
*
Specialized healthcare procedures requiring care by
specially trained adult (G-tube, tracheotomy,
cauterization). Takes medication, requires
positioning by bracing multiple times daily. Health
related intervention and direct 1:1 assistance at
least 45 minutes daily. Direct assistance with most
personal care. Requires two-person lift. Direct
support required with at least 76% or all personal
care and medical needs.
4
*
Severe level of behavioral incidents. Behavior
problems with potential for injury to self and
others, runs away, and aggressive daily.
Analysis of behavior has been completed and
the student has a well-developed BIP. Requires
constant and immediate supervision and
intervention from a specially trained adult to
prevent escalation into dangerous situations.
Requires 76%-100% adult support daily.
Participation in any setting requires constant
1:1 support. Requires verbal and physical
prompting to stay on-task and follow directions
76% or more of the time. Regularly requires
specific 1:1 instructional strategies.
4
*
IEP goals can be met through partial or full inclusion
in general education with extensive use of
accommodations and/or modifications. Requires
constant adult supervision to access curriculum.
Always requires 1:1 staff in close proximity for direct
instruction, safety, mobility, or behavioral
monitoring. Requires 1:1 assistance to go to and from
class. Requires verbal and physical prompting to stay
on-task and follow directions 76% or more of the
time.
*Attach a copy of documentation indicating frequency and duration over a period of time to determine future considerations of special circumstance instructional assistance.
22
Form 14 - SOUTH EAST CONSORTIUM SELPA
Special Circumstance Instructional Assistance
Behavior Intervention Plan
Student Name: __________________ Birthdate: __/__/____ IEP Date: __/__/____ Date of BIP: __/__/_____
This Behavior Intervention Plan is based on a Functional Behavior Assessment No Yes
If marked no, Behavior Intervention Plan is based on the following: -
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
The problem behavior impeding learning is (describe what it looks like)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
F
requency _________________________ Intensity _________________________ Duration _________________________
reported by _________________________________ and/or observed by ______________________________________
PREVENTION, PART I: ENVIRONMENTAL FACTORS AND NECESSARY CHANGES
What are the antecedents for the problem behavior? (Situations in which the behavior is likely to occur: physical setting, social
setting, instructional strategies, curriculum and activities, scheduling factors, degree of independence, degree of participation,
social interaction, degree of choice, etc.)
What environmental structure and supports are needed to reduce the problem behavior? (Provide specific examples)
A
NALYSIS, PART II: FUNCTIONAL FACTORS
Team believes the behavior occurs because:
Access:
__________________________________________________________________________________________________
Avoid:
___________________________________________________________________________________________________
Automatic Reinforcement:
___________________________________________________________________________________
Other:
___________________________________________________________________________________________________
FE
RB, PART III: FUNCTIONALLY EQUIVALENT REPLACEMENT BEHAVIOR
What team believes the student should do INSTEAD of the problem behavior? (Replacement behavior that meets the same
identified function of problem behavior)
List teaching Strategies/Necessary Curriculum/Materials that are needed (List successive teaching steps for student to learn
replacement behavior/s)
23
List reinforcement procedures needed for 1) establishing, 2) maintaining, and 3) generalizing the replacement behavior(s)?
S
election of reinforcer based on:
R
ESPONSE TO PROBLEM BEHAVIOR, PART IV: STRATEGIES
Student Behaviors
Staff Response
Student early escalation behaviors may include:
Staff response to early escalation behaviors may include:
(e.g. prompting relaxation strategies, offering distractions)
Student behaviors during problem behavior may include:
Staff response during problem behavior may include: (e.g.
monitor for safety, one step directions, neutral tone and affect
Student behaviors during de-escalation may include:
Staff response to promote de-escalation may include: (e.g.
model deep breathing, encouragement)
Student behaviors during post incident may include:
Post incident strategies may include: (e.g. offer choices,
refrain from discussing consequences)
Behavioral Goal(s) are part of the student’s IEP. See Goal(s) numbered:
_______________________________________________.
24
Form 15 - Special Circumstance Instructional Assistance Independence Behavior Intervention Plan
Checklist
*Attach a copy of the student’s Behavior Intervention Plan to this form.
Student:
ID #:
Date:
Age: Grade: DOB:
Eligibility:
Gen Ed Teacher:
School:
Sp Ed Teacher:
IEP Manager:
What are the target behaviors in the BIP?
_______________________________________________________________________________
_______________________________________________________________________________
☐Yes ☐No The request for SCIA is related to the identified target behaviors in the BIP.
☐Yes ☐No All interventions are developmentally appropriate for student.
☐Yes ☐No BIP is written with enough clarity and detail for any new staff to understand and implement.
☐Yes ☐No All implementers have a copy of the plan.
☐Yes ☐No All implementers understand and/or have training in the strategies contained in the plan.
☐Yes ☐No Support for the plan provided by the Case Manager is adequate.
☐Yes ☐No Student is making progress on the target behaviors. Indicate supporting evidence (e.g., grades,
rate of homework completion, duration of on-task behavior, frequency, and quality of social
interactions).
Explain:___________________________________________________________________
__________________________________________________________________________
Action(s):
☐ BIP is appropriate, and no modifications are needed.
☐ Revise BIP.
☐ Train support staff. Describe: _________________________________________________________
☐ Other
C
omments:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
25
Form 16 - Special Circumstance Instructional Assistance Independence Fade Plan
This Fade Plan is attached to IEP date: ________
Student:
ID #:
Date:
Age: Grade: DOB:
Eligibility:
Gen Ed Teacher:
School:
Sp Ed Teacher:
IEP Manager:
School Psychologist:
Prepared by:
Behavior Intervention Plan: Yes ☐ No ☐
Goal 1:
Procedures: What will be taught so that the student learns the replacement
behavior/skills? (Task analysis of skill development)
Arrangements:
(Where/When/Materials)
Measurement/Progress Monitoring Method:
(Who, how often, and how the data will be collected. If using a data sheet, please
attach)
Criteria for fading: (How will the data be evaluated to determine if intervention is
working?)
What are the adaptations/accommodations/activities to assist with promoting and sustaining independence?
(Generalization procedures, reduction in direct assistance, transfer of control to natural supports/cues and natural reinforcements)
Data Summary/Review of Independence Level (Recommended every 12 weeks or until SCIA is completely faded)
Baseline
(Frequency,
percentage, duration,
intensity, etc.)
Goal #1
Goal #2
Goal #3
Goal #4
Progress level:
Recommendation:
26
Form 17 - Review of Independence/Fade Plan to Determine Continued Need for Special Circumstance
Instructional Assistance
*This form should be completed, and this information should be reviewed at the next IEP meeting (within 3-6 months) to
determine the effectiveness of SCIA support.
Student:
ID #:
Date:
Age: Grade: DOB:
Eligibility:
Gen Ed Teacher:
School:
Sp Ed Teacher:
IEP Manager:
Observational Setting: Observer’s Name/Position or Title
Name(s)/Position of SCIA provider(s):
Description of current SCI Assistance provided (time, settings, specific tasks such as health, personal care, behavior, instruction,
inclusion/mainstream support):
Observation of student behavior, preferably a range of interactions as noted on original SCIA Rubric and Independence Plan
(including non-teacher-directed, teacher-directed, structured activities, unstructured activities, within the time frame that support
was originally necessary and is currently provided):
Description of results or efforts to increase student independence and progress on goal(s):
Current status per teacher/support staff/student/data collection:
Recommendations for increasing generalization (e.g., change time, or tasks; move to less structured settings; additional opportunity
for student independence; staff training, etc.):
Comments/Additional Recommendations:
27
Appendix Form A - Special Circumstance Instructional Assistance Assessment
Evaluation Report and Independence/Fade Plan Sample
Student:
ID #:
Date:
Age: Grade: DOB:
Eligibility:
Gen Ed Teacher:
School:
Sp Ed Teacher:
IEP Manager:
Evaluation Report Prepared By:
I. Reason for Referral and Rating from SCIA Rubric
Mr. Smith requested additional assistance for Leslie due to her distractibility and difficulty keeping up in the general education
classroom.
II. Background Information and Educational Setting (summarize special education and related services history; educational history, including academic
progress/assessments and progress on IEP goals; results of previous evaluations, if applicable; previous interventions and outcomes; educationally relevant health, developmental,
and medical findings; review of BIP; and disciplinary referral information).
Leslie has received special education and related services as a student with Autism since kindergarten. Currently, she receives
support in a RSP setting for 40% of each school day. Leslie receives Speech and Language services two times a week for 30 minutes
to address pragmatic skills. She also receives consultation from the Occupational Therapist ten times per year to address her fine
motor delay and sensory integration. Leslie’s general education homework is modified. Reading comprehension, written language,
and math goals are addressed in RSP using small groups and direct instruction.
A review of her IEP written on January 26, 2016 indicates that Leslie has made substantial progress on her self-help goal (i.e.,
feeding) and sensory integration goals. She has made partial progress on the following goals: reading comprehension,
communication (i.e., pragmatics), and behavior (i.e., verbal outbursts and homework completion). She has made minimal progress on
the following goals: written language, math (i.e., problem solving), fine motor, and behavior (i.e., on-task).
Leslie’s latest report card indicated B’s and C’s in all subjects. She receives appropriate accommodations so that she can access the
general education curriculum. Leslie scored Below Standards on the English/Language Arts and Math portions of the October SBAC
Interim Assessments.
A Behavior Intervention Plan was written at the end of last school year (05/15/16) and implemented for a short time before the end of
the school year. Ms. Keyser continues to implement the BIP in the RSP classroom. Mr. Smith has not yet been trained in
implementing the BIP in the general education classroom. The BIP targets on-task behavior and distractibility.
A review of Leslie’s discipline file indicated only two office referrals since beginning school at Central School in Kindergarten.
Leslie’s most recent Psycho-Educational Report (triennial evaluation in 2
nd
grade) indicated that she continues to qualify for special
education services as a student with Autism. She demonstrates delays in the following areas: academics, fine motor, communication,
self-help, and behavior. Please refer to report for additional information. Leslie was diagnosed with Asperger’s Syndrome in July
before beginning kindergarten.
III. Evaluation Procedures (include information regarding administration of tests in primary language of student by qualified personnel; validity of the evaluation; validity of tests
for the purpose for which they were used).
• Review of records, including IEPs and BIP
• Interviews with Parent(s), Teachers, and Student
• Observations
• Behavior Assessment System for Children (BASC)
• Vineland Adaptive Behavior Scales
Test results are a valid indication of Leslie’s present functioning based on the structure of this one-on-one setting and Leslie’s
interest in the tasks. There are no known cultural, environmental, or economic factors negatively influencing this evaluation. Leslie’s
primary language is English. Her ethnicity is identified as Asian and White. Racial, and ethnic background were considered prior to
selection and interpretation of evaluation procedures and measures. Additionally, assessment instruments are considered valid and
reliable based on the norm-referenced groups for each standardized test administered. However, all assessment procedures measure a
limited sample of a person’s total repertoire.
IV. Summary of Interviews and Observations (summarize results of observations over different settings where the child is displaying the problem behaviors/health
concerns/academic concerns to determine where and when support is needed).
Interviews and observations indicated that Leslie is most successful in the RSP classroom where instruction is at her academic level
and she receives more support in a smaller group setting. Leslie herself is keenly aware that she is less successful in the general
education classroom.
28
Leslie is distractible in general, but her distractibility becomes more obvious and disruptive in the general education classroom. In
the RSP classroom, a more intensive behavior management system is in place in which Leslie can earn points for on-task behavior
and asking for help. This system supports her use of appropriate behaviors. Mr. Smith indicates that he needs additional support with
Leslie as he is “running out of ideas.”
Leslie was observed to be on-task during structured activities such as reading a chapter with a peer buddy and performing her role in
a small collaborative group in the general education classroom as the “materials manager.” When instruction or tasks became less
structured, Leslie appeared to become confused about what she was supposed to be doing and was either quietly off-task or
disruptive. Her disruptions came in the form of off-topic questions or comments to her peer group. Leslie did not appear to know
how to ask for help when she did not know what to do. She received negative attention from peers for disrupting the collaborative
group.
A review of the rubric indicated No Concerns in Health/Personal Care. Moderate concerns were noted in Behavior (e.g., has
problems following directions and behaving appropriately without a BIP). Significant concerns were noted in the following areas:
Instruction (e.g., difficulty participating in a large group and requires low student/staff ratio).
V. Summary of Standardized and/or Curriculum-Based Assessments
(if applicable)
N/A
VI. Recommendations (include information regarding the need for specialized services, materials, and equipment; indicate if the student’s needs can be met in the regular education
classroom with the current level of support)
Mr. Smith and Ms. Keyser work together to modify the general education curriculum for Leslie; however, both have reported that
this is a challenging task. Leslie does benefit from access to the general education curriculum, but due to her delayed reading
comprehension abilities, it is often difficult for her to benefit from the activities in the general education classroom without
significant support. In the RSP classroom, Leslie thrives under the guidance of Ms. Keyser and Ms. Petry. She works well in small
groups, has shown progress, and enjoys her time in RSP. Leslie does not demonstrate the level of distractibility or off-task behavior
in RSP that is observable in the general education classroom. When offered tasks at her instructional level, with support made
available as needed, Leslie’s on-task behavior increases significantly.
It is therefore the recommendation of this evaluator that Leslie requires additional support in the general education environment to
focus on her increasing time on task, to work on the development of her ability to ask for help when needed, and to participate
independently in the general education environment. Leslie does not require additional support in the RSP setting to make progress
towards her IEP goals and Objectives. She also does not require additional support during recess or lunch, once she has chosen her
meal. Finally, it is recommended that Mr. Smith receive training in and implement the Behavior Intervention Plan that has been
developed.
Time/Subject Area
Support Needed
(Ratio, equipment, materials, etc.)
Does support
require
additional staff?
(please check)
8:00 - 9:20 General Education
Arrive, put away backpack, circle time, and self-help skills
☐
8:20 - 9:00 General Education
Center rotations, including OT and Speech
☐
9:00 - 10:00 RSP
Language Arts activities, small group, adult support 1:1
☐
10:00 - 10:30 RSP
Whole group technology/sensory tools, 2:1 adult support
☐
10:30 - 11:00 RSP
Math lesson and activities, 2:1 support
☐
11:00 - 11:30
Lunch Recess 3:1 adult support
☐
12:00 -12:45 General Education
Science Volunteer adult support/buddy reading
☐
12:45 - 1:00 General Education
Recess 3:1 adult support
☐
1:00 - 2:00 General Education
Social Studies peer support as reading buddy
☐
2:00 - 2:20 General Education
Get ready to leave, pack, get homework
☐
VII. Independence/Fade Plan (The Independence/Fade Plan is written to specifically address the needs of the student, current supports, schedule for assistance, and details for
implementing and fading the support).
GOALS
Baselines
29
(What are the replacement behaviors and/or academic goals for the
student?)
By December 2017, Leslie will demonstrate on task
behavior for 10 consecutive minutes independently
on 4 of 5 trials in the general education setting as
measured by teacher data.
10 consecutive minutes on 1 of 5 trials in the general education setting
VIII. Steps to Independence/Fade Plan (Describe the activities or environments where the replacement behaviors should occur).
1) Procedures:
(What will be taught so the student learns the replacement
behavior/skills? *Use task analysis of skill development.
1a) Arrangements:
(Where/when/materials)
1b) Level of support:
(Description of how and
who support changes as student independence increases)
Prompting; type; frequency; proximity of personnel; role
of teacher/IA
Leslie should be able to complete small
group and independent work during
timed activity centers in the special ed.
setting. In the general ed. setting, she will
be given points on a daily data sheet by
the SCIA support staff every ten minutes
for on task behavior and following
directions during independent work time.
She will receive bonus points for asking
for help using her “help card” and for
turning in homework. Points awarded
will be converted to Leslie receiving time
for preferred activities (i.e., puzzles,
working with a friend) within the general
ed. setting as agreed by the general and
special ed. teachers.
Positive reinforcements will be
determined between the special ed. and
general ed. teachers and Leslie. A “help
card” will be placed at Leslie’s desk.
Daily time interval data sheets will be
used to monitor on-task behaviors during
independent work. A timer will be used
to keep track of time intervals.
The SCIA support staff will document
time intervals and prompt and reinforce
desired behavior. She will share
behavioral data with the general ed.
teacher to determine earned positive
reinforcements.
2) Measurement/Progress Monitoring
Method:
2a) Decision Rule:
(How will the data be evaluated to determine if intervention is working?)
Data will be collected weekly and reviewed to measure the frequency that Leslie
exhibits on-task behaviors within 10-minute intervals during independent time in the
general ed. setting.
The SCIA support staff will monitor
Leslie’s on-task behavior during
independent work using the daily data
collection sheets.
2b) Criteria for fading and a description of the level of SCI support:
1. Leslie will demonstrate on-task behaviors for 10 consecutive minutes
independently 2 out of 5 trials in the general ed. setting over a two week period as
measured by teacher data. SCIA support staff will remain in close proximity,
documenting on-task behaviors during independent work and suing verbal, visual,
and gestural prompts as necessary.
2. Leslie will demonstrate on-task behaviors for 10 consecutive minutes
independently on 3 out of 5 trials in the general ed. setting over a two week period as
measured by teacher data. SCIA support staff will begin to fade proximity and
function more like a classroom aide when Leslie is successful. She will continue to
document on-task behaviors during independent work and use verbal, visual, and
gestural prompts as necessary.
3. Leslie will demonstrate on-task behaviors to 10 consecutive minutes independently
on 4 out of 5 trials in the general ed. setting over a two week period as measured by
teacher data. SCIA support staff will fade proximity and function more like a
classroom aide when Leslie is successful.
3) What are the adaptations/accommodations that will be used to promote and sustain independence?):
• Help card will be available
• Use of verbal, visual, and gestural prompts
• Begin to increase length of timer interval for documenting on-task behaviors
• Maintain positive reinforcements
Submitted by: ___________________________________
30
Appendix Form B - SOUTH EAST CONSORTIUM SELPA
Behavior Intervention Plan
Student Name: RP Birthdate: 1/1/2009 IEP Date: 1/21/2017 Date of BIP: 8/8/2017
This Behavior Intervention Plan is based on a Functional Behavior Assessment ☐ No ☒ Yes
If marked no, Behavior Intervention Plan is based on the following: -
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
The problem behavior impeding learning is (describe what it looks like) RP has difficulty eating his lunch independently. RP tends to
sit in front of his food and not eat. RP will throw his food and utensils, or attempt to elope from the table. There were multiple
incidents when he grabbed someone else’s food and took a bite.
Frequency Daily Intensity _________________________ Duration 20 minutes
☒ reported by Teacher and parent and/or ☒ observed by school psychologist
PREVENTION, PART I: ENVIRONMENTAL FACTORS AND NECESSARY CHANGES
What are the antecedents for the problem behavior? (Situations in which the behavior is likely to occur: physical setting, social
setting, instructional strategies, curriculum and activities, scheduling factors, degree of independence, degree of participation,
social interaction, degree of choice, etc.)
When RP is in the school cafeteria with the rest of the class and other classes during lunch time. When he is expected to eat his
food.
What environmental structure and supports are needed to reduce the problem behavior? (Provide specific examples)
RP requires someone to make sure he eats his food during lunch time and ensure he does not throw his food or try to leave the
table. RP needs enough space between him and another student, so he does not grab other students’ food.
ANALYSIS, PART II: FUNCTIONAL FACTORS
Team believes the behavior occurs because:
☐ Access:
__________________________________________________________________________________________________
☒ Avoid: RP is on a casein/gluten free diet and it is a possibility that the food is not reinforcing for him.
☐ Automatic
Reinforcement:__________________________________________________________________________________
☒ Other: Protest – It is possible that RP does not like the texture of the taste of the food which is puree type of food.
FERB, PART III: FUNCTIONALLY EQUIVALENT REPLACEMENT BEHAVIOR
What team believes the student should do INSTEAD of the problem behavior? (Replacement behavior that meets the same
identified function of problem behavior)
RP will eat his food independently following a visual prompt (task analysis), or following a verbal or gestural prompt without
throwing food or trying to leave the table.
List teaching Strategies/Necessary Curriculum/Materials that are needed (List successive teaching steps for student to learn
replacement behavior/s)
This plan will use a least-to-most prompting procedure: a) Visual prompt (task analysis), gestural prompt, verbal prompt, partial
physical prompt (light tap on the elbow), and physical assistance.
Each Monday, staff will review the task analysis on how to eat independently, and have RP engage in the role-play to
demonstrate each individual step. Staff will provide RP with specific feedback and encouragement to engage in behaviors. RP
will be reminded daily of expected behavior while referencing the task analysis visual 5 minutes before lunch time.
Fading Plan:
RP currently requires up to an average of 40 verbal or full physical prompts during lunch time to partially eat his lunch.
Month 1: The aide will provide verbal and/or physical prompting 100% of the time to establish and maintain the replacement
behavior.
Month 2: The aide will reduce the number of full physical prompts to no more than 30 daily.
Month 3: Reduce the number of full physical prompts to no more than 20 daily, and transferring the prompts to regular staff by
having regular staff implement the prompts.
*The team will reconvene and discuss level of support if the number of full physical prompts exceed 20 daily for five consecutive
days, or if student is successfully meeting the fading targets.
List reinforcement procedures needed for 1) establishing, 2) maintaining, and 3) generalizing the replacement behavior(s)?
If RP feeds himself independently (no physical assistance) when verbally or gesturally prompted to eat his food, RP will be
provided with specific praise (“Nice job eating lunch.”;’ “That’s a great bite!”) and a preferred edible (e.g., casein/gluten free
preferred snack) will be provided immediately.
If RP does not respond to the verbal prompt within 1 minute and needs to be physically assisted to feed himself, staff would still
provide a specific praise (“Nice bite.”), but no edible reinforcer.
If RP throws the food or utensil, use the next more intrusive prompt level (physical assistance) to show him the steps required to
eat his food. No reward or praise should be given if he throws his food or utensil. RP should be encouraged to try again.
Selection of reinforcer based on: Parent input
RESPONSE TO PROBLEM BEHAVIOR, PART IV: STRATEGIES
Student Behaviors
Staff Response
Student early escalation behaviors may include:
RP scans the cafeteria and begins to play with his food with a
fork, picking at it. RP will also look or stare at his neighbor’s
food.
Staff response to early escalation behaviors may include:
(e.g. prompting relaxation strategies, offering distractions)
Remind RP verbally to eat his food (“RP, please eat your food.”)
and wait about 1 minute. After 1 minute, remind RP of reinforcer
and use full physical assistance to show him what is expected
while verbalizing the steps to expected behavior. Immediately
praise RP for any expected behaviors or close approximations
to the alternative behavior.
Student behaviors during problem behavior may include:
RP throws his food and utensils and gets up from his seat and
begins to run away from the area.
Staff response during problem behavior may include: (e.g.
monitor for safety, one step directions, neutral tone and affect)
31
32
Using a neutral tone of voice, remind RP verbally of earning
reward for eating his food. Verbally tell other students nearby to
give him space.
Student behaviors during de-escalation may include:
RP returns and joins the class. RP may eat some of his food if
the class is still in the cafeteria.
Staff response to promote de-escalation may include: (e.g.
model deep breathing, encouragement)
Praise RP for all appropriate behaviors (e.g., “Thank you for
joining us.”).
Student behaviors during post incident may include:
RP is calm and following staff directions, re-engaging in
instruction or completing some work.
Post incident strategies may include: (e.g. offer choices,
refrain from discussing consequences)
Staff will avoid discussing the incident in length. Staff will remind
student of reinforcer if he is able to eat his food and refrain from
leaving the area. Staff will model for the student how to eat
independently and review the individual steps. Staff will have the
student demonstrate each step through a role-play and correct
any errors by providing specific feedback. Student will be
redirected to the next activity.
☒ Behavioral Goal(s) are part of the student’s IEP. See Goal(s) numbered: 1 and 2.
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