SAM!National!Pilot!Version!2.0!(November!2014)!Page!<!1!
Self%Assessment+of+MTSS+Implementation+(SAM)
Item+ 0+=+Not+Implementing+ 1+=+Emerging/Developing+ 2+=+Operationalizing+ 3+=+Optimizing+
Rating+
1. Leadership Domain (Items 1-5)
1. The!principal!is!actively
involved!in !a n d !fa cilit at es !
MTSS!implementation!
The!principal!does!not!
actively!support!MTSS.!
The!principal!communicates!an!
urgent!desire!to!implement!
MTSS,!participates!in!professional!
development!on!MTSS,!and!is!
establishing!a!MTSS!vision!
and!The!principal!actively!supports!
the!leadership!team !and !staff!to!
build!capacity!for!implementation!
and The Principal actively!
supports!data-based!problem
solving!use!at!the!school!+
2. A!leadership!team!is
established!that!includes!6<8!
members!with!cross<
disciplinary!representation!
(e.g.,!principal,!general!an d !
special!education!teachers,!
content!area!experts,!
instruction a l!su p p o rt!s ta ff,!
student!support!personnel!
1
)!
and!is!responsible!for!
facilitating!MTSS!
implem en ta tio n !
2
No!leadership !team!with!
explicit!responsibility!for!
leading!M T S S !
implem en ta tio n !e xis ts!
A!leadership!team!exists!
that!includes!cross-
disciplinary!representation
and'The!leadership!team'has!
explicit!expectations!for!
facilitating!MTSS!implementation!
and!The!leadership!team'members!
have!the!beliefs,!knowledge,!and!
skills!to!lead!implementation!efforts!
3. The!leadership!team
actively!engages!staff!in!
ongoing!professional!
development!and!coaching!
3
!
necessary!to!support!MTSS!
implem en ta tio n !
The!leadership!team!does!
not!have!a!needs<based!plan!
to!provide!staff!with!
professional!development!or!
coaching!to!support!MTSS!
implem en ta tio n !
A!needs!assessment!is!conducted!
to!gather!information !on!b eliefs,!
knowledge,!and!skills!to!develop!
a!professional!development!plan!
to!support!MTS S!im plementation!
and!A!professional!development!
plan!is!created!based!on!the!needs!
assessment!and!used!to!engage!
staff!in!ongoing!professional!
development!and!coaching!+
and!Ongoing!professio n a l!
development!activities!are!
informed !b y !d at a!c o lle cte d !o n !th e!
outcomes!of!professional!
development!and!coaching!for!
continuous!improvement!
4. A!strategic!plan!for!MTSS
implem en ta tio n !is !d ev elo p e d!
and!aligned!with!the!school!
improve m e n t!p la n!
No!strategic!plan!for!MTSS!
implem en ta tio n !e xis ts!
Leadership!team!is!engaging!
district,!family,!and!community!
partners!to!identify!stakeholder!
needs,!resources!for,!and!barriers!
to!MTSS!imp lem en tation !
and!As!part!of!the!school!
improve m e n t!p la n n in g!p ro c e ss! a!
strategic!plan!is!developed!that!
specifies!MTSS!implementation!
4
!
and!A!strategic!plan!for!MTSS!
implem en ta tio n !is!update d!as!
needed!based!on!student!outcome!
and!implementation!fidelity!data!as!
part!of!the!school!improvemen t!
planning!process!
5. The!leadership!team!is
actively!facilitating!
implem en ta tio n !o f!MTSS!
5
!as!
part!of!their!school!
improve m e n t!p la n n in g!
process!
The!leadership!team!is!not'
actively!engaging!in!efforts!to!
facilitate!MTSS!
implem en ta tio n !
The!leadership!team!engages!in!
action!planning!!
and!has!created!a!strategic!plan!
to!facilitate!implementa tion !of!
the!critical!elements
6
!of!MTSS!
and!The!leadership!team!provides!
support!to!educators!implementing!
the!critical!elements!of!MTSS!
identified!in !th e !stra te g ic!p la n !
and!The!leadership!team!uses!data!
on!implementation!fidelity!of!the!
critical!elements!of!MTSS!to!
engage!in!data-based!problem
solving!for!the!purpose!of!
continuous!school!improvement!
The SAM instrument was developed by Florida PS/RtI Project Staff and Florida’s PBS: Effective Practice. Permission was granted to the Indiana IEP Resource Center to utilize the tool.