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SAIL Student Data Referral Form
Please complete the form in its entirety.
Step 1 - Student Information
Date *
Your answer
What building is the student located? *
Last Name *
Your answer
First Name *
Your answer
Grade *
Your answer
Teacher *
Your answer
Date of Birth *
Your answer
Gender *
Name of Parent/Guardian *
Your answer
Parent/Guardian contact prior to referral *
Step 2 - Assess Concern (s)
Academic Information - Compare this student to other students on the same grade level. *
Indicator Below Average, Average, Above Average
Below Average (1)
Average (2)
Above Average (3)
NA/Unknown
Spoken Language Skills
Listening Comprehension Skills
Reads aloud with fluency
Uses decoding skills
Comprehends text read
Comprehends word meaning
Performs mathematical computations at expected grade level
Applies mathematical reasoning at expected grade level
Processes information and formulates answers quickly
Expresses ideas in writing
Applies effort/is motivated
Exhibits organizational skills
Is able to work independently
Is able to work as a member of a group
Understands and follows directions
Completes tasks on time
Retains instruction from week to week
Uses test-taking strategies
Spells words at expected grade level
Test-taking anxiety
Total Score
1-20 - Student is performing significantly BELOW AVERAGE in comparison to peers.
21-40 - Student is AVERAGE in comparison to peers.
41-60 - Student is ABOVE AVERAGE in comparison to peers.
Behavioral Information - rate student behavior based on observation. *
Below Average (1)
Average (2)
Above Average (3)
Follows classroom rules
Complies with adult requests
Expresses dissatisfaction appropriately
Works cooperatively with peers
Begins tasks promptly
Shifts from one uncompleted task to another
Responds appropriately to redirection
Interrupts instruction
Seeks attention from peers
Behavior results in discipline referrals
Total Score:
1-10 - Student is performing significantly BELOW AVERAGE in comparison to peers.
11-20 - Student is AVERAGE in comparison to peers.
21-30 - Student is ABOVE AVERAGE in comparison to peers.
Please Provide the Top Two Concerns
From the above checklists, please PRIORITIZE THE TOP TWO CONCERNS you have for this student. The two choices will be the focus of the targeted interventions in the SAIL meetings. For both areas of concern, you will provide baseline data, complete progress monitoring for the chosen interventions, and provide follow-up data. This data will be used to make decisions during the SAIL process
Concern #1: *
Your answer
Concern #2: *
Your answer
Identify the situations where the concerns occur most/least often: *
Your answer
STEP 3 STUDENT STRENGTHS/INCENTIVES
List TWO strengths the student best demonstrates: *
Your answer
List incentives/rewards that the student responds to in a positive way: *
Your answer
The student's preferred learning style is *
STEP 4 - BACKGROUND INFORMATION
How many days has this student been absent this year to date? *
Attendance Data
Your answer
Reasons for absences: *
Your answer
Has the student ever been suspended for disciplinary reasons during the current school year? *
Discipline Data
If the previous question was answered with a yes, please explain the reasons for the suspension.
Your answer
Has the student been retained? *
Related Academic Information Data
If the student was retained, what grade?
Your answer
Has the student been previously referred to SAIL? *
Does the student have a 504 plan? *
Does the student receive speech services? *
Does the student attend Title or other intervention? *
Does the student have a medical diagnosis which may be significantly impacting their learning? *
Does the student take medication for any medical condition? *
Related Personal Information
Please check all applicable to student:
Please describe "other" if checked above.
Your answer
STEP 5 - BASELINE DATA INFORMATION
Current Grades - On Grade Level? *
Yes
No
ELA
Mathematics
Science
Social Studies
Current Grades - Grade % *
90% or above
80% or above
70% or above
60% or above
50% or above
ELA
Mathematics
Science
Social Studies
Historical Evaluation of Grades: *
Grades:
Required
Curricular Assessments:(test/quizzes/projects/etc) *
Please list assessments and corresponding information - Types of Assessments/Student Grade/Class Average
Your answer
STAR Reading - Please list the percentile rank. *
Your answer
STAR Reading - Please list the grade equivalent. *
Your answer
STAR Reading - Please list the category/color. *
Your answer
STAR Math - Please list the percentile rank. *
Your answer
STAR Math - Please list the grade equivalent. *
Your answer
STAR Math - Please list the category/color. *
Your answer
STAR Scores:
What grade level did the STAR score drop?
**Please bring all assessment data with you to the SAIL meetings.**
Please List Concern #1
Please list concern #1
Your answer
Baseline Data Measure for Concern #1
Your answer
Baseline Data Score for Concern#1
Your answer
Please list Concern #2
Your answer
Baseline Data Measure for Concern #2
Your answer
Baseline Data Score for Concern #2
Your answer
****Please bring current baseline data with you to the SAIL meetings for the two areas of concern you listed.***
STEP 6 - INTERVENTIONS ATTEMPTED
Please document the attempts to meet the student's needs within the core academic classroom:
Please choose "Improved", "No Change", or "Not Attempted" for each. *
Improved
No Change
Not Attempted
Alternative reading materials
Use of graphic organizers/study sheets
Flexible small groups
Read with student
One on one with teacher/aide
Increased use of manipulatives
Help from volunteer tutor (peer/adult)
Increase repetition and drill
Skill-based learning groups
Increase positive reinforcement
Break assignments into small steps (segmenting)
Frequent checks for understanding
Provide rewards for task completion
Enlist parent support to review skill at home
Alternative math materials
Additional instructional time
Change in environment or seating arrangement
Assistive technology
Change pace
Modified curriculum
Written sequential insturctions
Addressing learning styles
Homework and practice
Cooperative learning
Setting objectives and providing feedback
Verbal prompts
Cuing and signaling
Listening to reader
Varied materials given
If you used instructional software, please list
Your answer
Attempts at Concern(s) Resolution *
Of the four areas listed below, which have been changed in some way in an attempt to address the concern(s)? Check the area(s) and describe what was attempted.
Required
Please list the area of concern and describe in detail what was attempted. *
Give duration and describe evidence of student being successful or not successful. (Instruction, Presentation, Materials, Environment, or other)
Your answer
STEP 7 - ADDRESSING PROBLEM BEHAVIOR
Teacher completes this section ONLY if student is being referred to SAIL for behavior concerns.
Does this student have a behavior concern?
Next
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