PBSD 1892 (Rev. 6/4/2020) ORIGINAL - Support Services
Regular Education Chronic Behavior Interventions
Referral Procedures Checklist
The Support Services designee and the sending school's Alternative Education (AE) contact will review the referral packet, sign this
checklist and have the SAC principal sign. The principal will attach the packet to PBSD 2541 and will route to the Support Services
work queue. Support Services will forward the packet to the Disciplinary Review Committee to be placed on the agenda.
Birth DateLast NameM.I.First NameStudent ID #
Current School Home SchoolCurrent School #
Person Completing Packet Job Title
Phone # E-mail Address
A. Principal's designee schedules a School Based Team (SBT) meeting and invites the following:
B. Current school School Based Team collects the following documentation pertaining to student performance, attendance,
disciplinary infractions and behavior intentions:
C. Responsibilities of SBT during meeting:
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1. Review documentation from section B of this checklist, attach all documentation
2. Document in PBSD 1051 Conference/Staffing Record
a. Previously implemented interventions recommended by SBT for behavior (academic if applicable) and results
b. Input from parent/guardian (if in attendance, via telephone, or in writing)
c. Recommendation of appropriate placement
1. Support Services designee (attendance required)
7. General education teacher
2. School administrator 8. School guidance counselor
3. Custodial parent/guardian
9. 504 designee/representative (if appropriate)
4. Student
10. ELL representative (if appropriate)
5. School psychologist, BHP and/or behavior coach
11. Translator (if appropriate)
6. SBT leader
12. Juvenile probation officer or outside agency
representative (if appropriate)
1. PBSD 2106 Problem Solving/School Based Team (PS/SBT)
Mandatory Referral
7. PBSD 1687 Progress Monitoring Plan for Grades 6
through 12 (if appropriate)
2. PBSD 1549 Functional Behavioral Assessment, PBSD
2406 Behavior Intervention Plan, PBSD 2514 RtI
Functional Behavioral Assessment Parental Consent
8. PBSD 1595 504/ADA Accommodation Plan Middle/High
School (if appropriate)
3. Documented contacts with custodial parent/guardian
regarding areas of concerns proposed interventions,
progress status and discussion of possible AE consideration
9. Copy of certified mail receipt, dated prior to meeting,
notifying parent of AE referral.
4. SBT notes documenting meetings to address targeted
10. PBSD 2209 Manifestation of Disability Determination
Process For Students with Section 504 Plans
5. PBSD 2318 Response to Intervention (RtI) Progress
Monitoring Log (6-8 weeks of evidenced based interventions)
11. PBSD 2491 Document Relating to Parental Input and
6. PBSD 2284 Academic/Behavior Intervention Plan
12. PBSD 1468 Section 504/ADA Evaluation and
Re-evaluation (if appropriate)
PBSD 1892 (Rev. 6/4/2020) ORIGINAL - Support Services
Last NameFirst NameStudent ID #
Regular Education Behavior
Interventions Referral Procedures
D. If the SBT recommends a referral to the Discipline Review Committee for a Chronic Behavior Assignment to Alt Ed Behavior
Intervention Program, the sending principal's designee and Support Services designee coordinate the following items to be included
with the Referral Packet:
1. All documentation from items B and C of this checklist
2. All PBSD 1051 Conference/Staffing Records including SBT and follow-up
3. PBSD 1546 Parent Acknowledgment of Intervention Assignment which documents written notification to custodial parent/
guardian regarding the right to due process and the right to request an evaluation to consider eligibility for Exceptional
Student Educational services
4. Updated PBSD 1687 Student Progress Monitoring Plan for Grades 6 through 12 signed by principal, teacher/guidance
counselor and custodial parent/guardian (for any student currently failing Reading, English/Language Arts, or Mathematics
and/or any student whose Miscellaneous Academic Information tab indicates the need for a PMP)
5. Updated PBSD 1595 504/ADA Accommodation Plan Middle/High School (if appropriate)
E. Indicate the recommended program:
NOTE: The sending school is responsible for arranging transportation.
Intensive Transition South
Turning Points Academy
Crossroads Academy
Behavior Interventions
Middle and High School
F. Signing below indicates that:
(1) the Referral Packet is complete, (2) the referred student meets the criteria for placement in the recommended program and (3)
the referred student meets immunization requirements
Signature of Principal
Signature of AE Contact (sending school)
Signature of Support Services Designee
Forwarded to Discipline Review Committee
Uploaded to DRC
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