NC DPI Exemplar Recognition Criteria Required content: The information on slides 2 - 14 is required information for your power point

Exemplar Application PowerPoint Date: 2016-2017 Slide #1 Name of School Name of school, LEA Address Phone Number (Area) ###-#### County Region Exemplar Application PowerPoint Date: 2016-2017 NC DPI PBIS

School Demographics This information is included on the slide. Grade levels served by school Student enrollment numbers Number of faculty/staff members Ethnicity breakdown

PBIS Team Information Include role within PBIS team (Ex: Data analyst) Slide #3 In-School Coach, with contact information Team members Include role within PBIS team (Ex: Data analyst) Include position at school (Ex: 7th grade teacher) NC DPI PBIS

Outcome Data-Showing Growth Slide #4 Achievement data, EOG/EOC scores, math scores, reading scores, etc. Display in graph form over the past three years (at least) If there has been a decline in the growth over the past three years, include past data to indicate improvement trends. Provide a written explanation of the decline. NC DPI PBIS

Outcome Data-Showing Growth Slide #5 Outcome Data-Showing Growth Office Discipline Referral (ODR)* Display in graph form over the past three years (at least) If there has been a decline in the growth over the past three years, include past data to indicate improvement trends. Provide a written explanation of the decline. This data will be submitted via the Discipline Data Summary (DDS) Spreadsheet as well as on this slide. Explanation Example: There were 3 consecutive years of reduced office referrals but this year there is an increase because Educator’s Handbook is being used and the improvement is consistent data reporting has increased scores.

The team was seeing a steady decline in office referrals since 2012 when PBIS was fully implemented. In 2015 our district changed our reporting for discipline from power school to Educators Handbook. Staff is now reporting behaviors more consistently. It was our expectation that during this transition year we would see an increase in our ODR scores. This improved data reporting has allowed us to continue to grow and improve systems and services for students.

Data from the 2015-16 academic year concludes that office discipline referrals have decreased significantly throughout the year.

Outcome Data-Showing Growth Slide #6 Outcome Data-Showing Growth Share one additional data point on this slide. Examples: suspension data, expulsion data, EC referral data, attendance, climate surveys, ethnicity reports, closing the disproportionality gap, bus referrals, staff retention data, etc. If there has been a decline in the growth over the past three years, include past data to indicate improvement trends Provide a written explanation of the decline.

Teaming and Referral Process Slide #7 Teaming and Referral Process Referral Process for Supplemental and Intensive Support. Brief description of the referral process and a visual representation through a table, chart, graph etc., Flow Chart Data Decision Rules Other

Tier 1 Implementation Components to add: Slide # 8 - 10 Components to add: Systems of practice, organizational structures Matrix (one Slide) Acknowledgement systems(one slide) Consequence grids(one slide) Others Possible action items to grow initiative in this area next year. The scores can be depicted on slide 7 NC DPI PBIS

Tier 2 Implementation Components to add: Slide #11 -12 Components to add: Systems of practice, organizational structures Describe two to three Tier 2 evidence based intervention in place and how data is collected and used to improve outcomes for students (one slide per intervention) Data to support growth: sustainability, durability Progress monitoring data for secondary interventions Possible action items to grow initiative in this area next year Scores can be depicted on slide 7 NC DPI PBIS

Tiered Fidelity Inventory (TFI) 80% or better on Tiers 1, 2 and 3 Tier 3 Implementation Slide #13 - 14 Components to add: (up to two slides) Systems of practice, organizational structures Describe two to three Tier 3 evidence based intervention in place and how data is collected and used to improve outcomes for students (one slide per intervention) Data: sustainability, durability Tiered Fidelity Inventory (TFI) results for tertiary implementation Data collection strategies, summaries for tertiary student data and interventions Individual student data Possible action items to grow initiative in this area next year. SET 95%/BSET 85% Tiered Fidelity Inventory (TFI) 80% or better on Tiers 1, 2 and 3 Scores can be depicted on Slide 7 NC DPI PBIS

Outcome Data Tiered Fidelity Inventory Scores: SET Scores: Tier 1 Year 1 Year 2 Year Score Year 1 Year 2 Year 3

Any sides from this point on are Optional

Integration of Initiatives MTSS Responsiveness to Instruction Character Education Literacy Bully prevention programs Classroom strategies Problem-Solving strategies (Ex: TIPS) Others NC DPI PBIS

District Implementation (optional) Visibility within LEA, leadership teaming Political support strategies Policy change or integration Training/coaching capacity building Evaluation/assessment for LEA Fidelity of implementation NC DPI PBIS