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STUDENT, STAFF & SUPPORT TEAM (SSST) REFERRAL FORM

ID#:

Student Name:

Date of
Birth:

Date:

Contact Information:
Teacher Name:

Grade:

People I wish to invite to SSST:

Person Making Referral:

Parent Contacted Prior to


SSST referral?

Language Spoken at Home

Parent Name(s)

Parent Phone:
Home
Work
Cell

Check the areas of concern(s):


Academic
Poor Reading
Skills
Poor Math
skills
Poor Spelling
Poor Writing
Study Skills
Incomplete
assignments
Doesnt work
well w/others
Doesnt work
well
independentl
y
Declining
grades
Slow rate of
work
Doesnt
follow
directions
Disorganized
Other _____

Problem
Behaviors
Aggressive
Non compliant
Poor attention
Easily distracted
Destroys property
Steals/Cheats/lies
Avoided by peers
Argumentative/D
efiant
Work completion
Withdrawn
Disruptive
Poor attendance
Bullies others
Victim of Bullying
Other _________

Communicat
ion
Language
Fluency
Articulation
Voice
ELL
other

Personal Care
dressing
hygiene
organization
glasses
Agitated/Nerv
ous
Sleeps in
class
Obese
Under-weight
Uncoordinate
d
Evidence of
selfmutilation
Burn marks
Appears
sickly
other

Health
visual
acuity
visual
tracking
hearing
physical
seizures
medication
gross/fine
motor
other

Contributing
Factors
curriculum
trauma
personal
loss
anxiety
peers
family
truant
tardy
other

Other Comments/Concerns:

Positive Attributes/Strengths:
Positive Attitude
Hard working
Trustworthy
Works well in
groups
Works well
independently
Self-confident
Takes pride in work

High expectations
of self
Organized
Good sense of
humor
Cooperates
Responsible
Creative
Has leadership
qualities

Where do the problem(s) occur?


Classroom
Cafeteria
Hallway
Bus
Home
Special Classes
Other _____________________________

Transitions easily
Takes pride in
appearance
Athletic
Musically talented
Artistically
talented
Accepts
suggestions
Kind to classmates
Popular with
classmates

Good memory
skills
Completes
homework
Respectful toward
adults
Enjoys helping
others
Articulate
Problem solving
skills
Takes/follows
directions well

Absences and Tardies:


To date this school year _______ absences;
_____ tardies
Last school year _______ absences; _______
tardies
Suspensions this school year: ________
Suspensions last school year: ________

Strategies and Results: Check all that apply and provide any results for most effective strategies
tried.
General
Review
Review files
Talk w/ parent
Talk w/
previous
teacher
Seek peer
help
Classroom
Assessment

Modified
Environmen
t
Change
Seat
Provide
quiet space
Provide
larger space
Encourage
work breaks
other

Modified
Presentatio
n
pre-teach
give extra
practice
change
pacing
give extra
feedback
provide
patterns
vary

Modified
Curriculum/
HW
change task
size
change color
provide
computer
provide
calculator
use visuals/
manipulative
s

Modified
Expectation
s
group
product
individ.
Product
make it
easier
more time
tutor/mentor
alternate
response

Results

materials
increase
instructional
time
planned
positive
reinforce
other

change
instruction
provide a
model
other

emphasize
quality over
quatity
other

What do you hope to gain from this meeting?


Suggestions/suppo
rt

Behavior Plan

SpEd Referral

Other:

Teachers bring the following to the SSST meeting: Work samples, assessment scores, reading
rate/accuracy, anecdotal notes, incident reports, other data. This information can be attached to this
form. Please see the Student Data and Evidence page for suggested data.

Student Data and Evidence:


Documentation must be provided for each student concern. The following are examples of the
types of evidence that may be used by the SSST team to determine appropriate response.
Check off each type of documentation that you are submitting and attach to this referral form.

Student work samples


Observations
Class quizzes and tests
Curriculum-based measures
Student portfolio
Student interview notes
Parent interview notes
Interviews with colleagues and/or specialists (summary notes)
Attendance records
Record of discipline referrals
Other: Specify

Work attached.

STUDENT, STAFF & SUPPORT TEAM ACTION PLAN # ______


(To be completed during SSST meeting)

ID#:

Student Name:

Date of
Birth:

Date:

Contact Information:
Teacher Name:

Grade:

Person Making Referral:

Language Spoken at Home

Parent Contacted Prior to


SSST referral?

Parent Name(s)

Parent Phone:
Home
Work
Cell

Review Date of Current Plan: ________________________

Current Goal for Intervention:

Strategies for Intervention:


Specific
Interventions

Frequency &
Duration

Person
Responsible

Progress Monitoring
Evidence (attach notes,
meetings, assessment
documentation, work
samples, etc. as
appropriate)

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