1. NC DPI Exemplar Recognition Criteria
Required content:
The information on slides is required information for your power point

2. 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:
NC DPI PBIS

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

4. 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

5. 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

7. 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.

8. 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.

9. Data from the academic year concludes that office discipline referrals have decreased significantly throughout the year.

10. 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.

12. 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

13. Tier 1 Implementation Components to add:
Slide #
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

14. 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

15. Tiered Fidelity Inventory (TFI) 80% or better on Tiers 1, 2 and 3
Tier 3 Implementation
Slide #
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

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

17. Any sides from this point on are Optional

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

19. 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