1. Intervention Process Checklist
Pre-referral Documentation (must be completed and submitted prior to initial SAT meeting):
_____ Tier I Implemented for at least 4 – 6 weeks
_____ Tier II Implementation for at least 4 – 6 weeks
_____ Documentation of effectiveness of the interventions
_____________________________________________________________________________
Initial Tier 3 Meeting (SAT)
Date: _______________
_____ Vision/Hearing Screening completed prior to meeting
Passed Vision: Yes No Passed Hearing: Yes No
_____ Parent Input Form
_____ Tier III Implemented
_____ Other documentation forms as necessary.
Action taken: ___ Continue Interventions ___ Modify Interventions
Follow-up SAT Meeting
Date: _______________
_____ Intervention Updates
_____ Other documentation forms as necessary.
Action taken: ___ Continue Interventions ___ Modify Interventions
___ Refer to EC ___ Exit Tier III
Follow-up SAT Meeting 2
Date: _______________
_____ Intervention Updates
_____ Other documentation forms as necessary.
Action taken: ___ Continue Interventions ___ Modify Interventions
___ Refer to SPED ___ Exit Tier III
EC Referral
_____ SAT Chairperson submits paperwork to EC – date: ________________