1. Exemplar Application Powerpoint Date: (School Year: YYYY/YYYY) Summer Contact Name : Summer Contact Phone Number: Revised NC PBIS 10-25-2013

2.  Coach, with contact information  Team members List with role within PBIS team (Ex: Data analyst) List position at school (Ex: 7 th grade teacher)

3. Name of school, LEA Address Phone Number (Area) ###-#### County Region

4.  Grade levels served by school  Student enrollment numbers  Number of faculty/staff members  Ethnicity breakdown

5. Components to add:  Systems of practice, organizational structures Matrix Acknowledgement systems Consequence grids  Data to support growth: sustainability, durability Implementation Inventory results (IIO) for Universals SET or BSET scores ODR reports  Possible action items to grow/sustain initiative in this area next year

6. Components to add:  Systems of practice, organizational structures Problem-solving group meetings Mentoring programs Check-In Check-Out initiatives Others  Data to support growth: sustainability, durability Implementation Inventory (IIO) -results for secondary implementation ODR reports (or other data) as related to children with chronic behaviors or secondary interventions  Possible action items to grow/sustain initiative in this area next year

7. Components to add:  Systems of practice, organizational structures Teaming/referral flow charts Problem-solving efforts Teacher-led behavior support strategies Student contracting efforts  Data: sustainability, durability Implementation Inventory results on tertiary implementation Data collection strategies, summaries for tertiary student data and interventions Individual student data  Possible action items to grow/sustain initiative in this area next year

8.  Academic Data: Achievement data, EOG/EOC scores, math scores, reading scores, etc. Aggregate data that shows improvement across at least 2 years, including data from the current school year  Behavior Data: Office Discipline Referral, suspension data, expulsion data, EC referral data, climate surveys, ethnicity reports, etc. Aggregate data that shows improvement across at least 2 years, including data from the current school year If you see growth over a period of more than two years, but a decline during consecutive years, please show the pattern of growth data in previous years

9.  EBS Self-Assessment (pbisapps)  Staff Retention data  Climate surveys Teacher Working Conditions YRBS (Youth Risk Behavior Survey) YRBS School-created climate survey  Special Education Referral Information  Attendance rates

10.  Responsiveness to Instruction  Character Education  Literacy  Bully prevention programs  Classroom strategies  Problem-Solving strategies (TIPS or other)  Others

11.  Visibility within LEA, leadership teaming  Political support strategies  Policy change or integration  Training/coaching capacity building  Evaluation/assessment for LEA  Fidelity of implementation