1. Exemplar Application Powerpoint Date: 2014-2015 NC DPI PBIS

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

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

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

5. Components to add:  Systems of practice, organizational structures Matrix Acknowledgement systems Consequence grids Others  Data to support growth: sustainability, durability Implementation Inventory results for universal implementation SET scores ODR reports NC DPI PBIS

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 results for secondary implementation ODR reports as related to children with chronic behaviors or secondary interventions  Possible action items to grow initiative in this area next year NC DPI PBIS

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 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 NC DPI PBIS

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

9.  Achievement data, EOG/EOC scores, math scores, reading scores, etc. Aggregated to over the past two years, at least  Office Discipline Referral (ODR) *, suspension data, expulsion data, EC referral data, climate surveys, ethnicity reports, closing the disproportionality gap, etc. Aggregated over the past two years (at least) 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 * This data will be submitted via the Discipline Data Summary (DDS) Spreadsheet. NC DPI PBIS

10. (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