SPLASH Module 1 - Supplementary

Consultant Information

Cooperative	Choose One Big East Educational Cooperative Caveland Educational Cooperative Central Kentucky Special Education Cooperative Jefferson County Kentucky Valley Educational Cooperative Northern Kentucky Educational Cooperative Ohio Valley Educational Cooperative River Region Cooperative Upper Cumberland Cooperative Western Kentucky Cooperative Wilderness Trail Cooperative
First Name
Last Name
Method of Content Delivery	Choose One Face to Face Small Group Webinars Self-guided *Other
*Other, specify
Mentoring/Coaching: Time with teacher in support of module content understanding and delivery	Choose One Less than 1 hour 1-2 hours 2-3 hours 3-4 hours 4-5 hours 5 or more hours

Teacher Information

District	Allen County Ballard County Barren County Beechwood Independent Boone County Bowling Greeen Independent Breathitt County Breckinridge County Calloway County Campbell County Clay County Corbin Independent Elizabethtown Independent Estill County Hardin County Jackson Independent Jefferson County Knox County Lawrence County Madison County Meade County Nelson County Oldham County Owsley County Todd County Warren County Choose One
School Name
First Name
Last Name
Grade Level (select all that apply)	Kindergarten 4th Grade 6th Grade 9th Grade 1st Grade 5th Grade 7th Grade 10th Grade 2nd Grade 8th Grade 11th Grade 3rd Grade 12th Grade
Classroom Setting (select all that apply)	Full Inclusion Collaboration Resource Self-Contained *Other - please specify below
*Other, specify

Observation remarks should be observable and measurable.

Key: 1=No Evidence, 2=Minimal Understanding, 3=Partial Implementation, 4=Full Understanding/Implementation

IEP	Understanding/ Implementation Level	Observation Notes Strengths and challenges
Teacher and staff know & understand the student's IEP Objectives	1 2 3 4 n/a
Teacher and staff know the amount of time the student will spend in special education and regular education (including time with related services )	1 2 3 4 n/a
Annual goals on the student's IEP reflect content standards from the general education curriculum	1 2 3 4 n/a
Collaboration is occurring with the regular education teachers to ensure implementation of the IEP	1 2 3 4 n/a
Understand the components of an IEP (Present level of performance, specially designed instruction, accommodations, etc…)	1 2 3 4 n/a
Teacher collects data on IEP objectives a minimum of twice per week	1 2 3 4 n/a
Teacher analyzes data	1 2 3 4 n/a

 

Schedule	Understanding/ Implementation Level	Observation Notes Strengths and challenges
Teacher has a master schedule that includes students and paraprofessionals (with their responsibilities/activities)	1 2 3 4 n/a
Students have access to their own schedule (adapted to meet their needs	1 2 3 4 n/a
Paraprofessionals have access to a schedule that lists their duties	1 2 3 4 n/a

 

Behavior	Understanding/ Implementation Level	Observation Notes Strengths and challenges
Function of Behavior (avoid something/gain something)	1 2 3 4 n/a
Understand antecedent, behavior, and consequence	1 2 3 4 n/a
Understands concept of reinforcement positive/negative	1 2 3 4 n/a
Understands concept of Premack Principal/planned ignoring	1 2 3 4 n/a

Paraprofessionals	Understanding/ Implementation Level	Observation Notes
Teacher communicates expectations to the paraprofessional(s)	1 2 3 4 n/a
Frequent and on-going communication between teacher and Paraprofessional(s)	1 2 3 4 n/a
Scheduling of paraprofessionals (role and responsibilities)	1 2 3 4 n/a

Action Plan/Next Steps

Date (MM/DD/CCYY)

Coach Responsibilities

Teacher Responsibilities