SI 2019 Breakout Session Proposal
Please submit this form if your school is interested in presenting a standard Breakout Session (75 minutes).
Identifying Information
Person Submitting Proposal *
Your answer
Job Title *
Your answer
Email Address *
Your answer
School District: *
Your answer
Building Name: *
Your answer
Grade Levels Served: *
RPDC Region: *
MO SW-PBS Training Level: *
Please select the MO SW-PBS training level that your building is currently participating in.
2017-2018 MO SW-PBS Recognition Status: *
Fidelity of Implementation Criteria
2017-2018 and 2018-2019 MO SW-PBS data submission and implementation data will be reviewed to ensure that building is an active participant with MO SW-PBS and implementing SW-PBS with fidelity.

This verification includes:
1. 2017-2018 Self-Assessment Survey (SAS) Schoolwide, Non-classroom and Classroom sub scale scores of at least 70% (please review your Total Score report at www.pbisapps.org)
2. Completion of 2018-2019 School Safety Survey (SSS)
3. Submission of 2018-2019 quarterly data (Quarter 1)

Number of Certified Staff in your building *
Your answer
Number of responses on the Self-Assessment Survey (SAS) *
Your answer
Schoolwide *
% In Place
Your answer
Non-classroom *
% In Place
Your answer
Classroom *
% In Place
Your answer
Breakout Session Information
All proposals will be reviewed by a statewide committee. Alignment with SW-PBS Essential Components is required. Any and all practices and interventions presented must be evidence based.
Select the Summer Institute Strand that is most applicable for the proposed session: *
For a full description of each strand, please go to: http://pbismissouri.org/si/
Indicate the name of the MO SW-PBS Consultant that will be your Session Collaborator. *
The Session Collaborator is a MO SW-PBS Personnel that will review session materials prior to the Summer Training Institute, introduce the school presenters, provide the research base for the session topic, and then close the session.
Your answer
Proposed Session Title: *
Your answer
Provide 2-3 session outcomes (practices, systems, or data that educators can take home and do tomorrow). These outcomes will be used in the conference brochure. *
Begin your outcomes with "Attendees will." For example: Attendees will use flowcharts to follow an efficient process; identify the responsibilities of a Tier 2 Team; consider outcomes of a tiered coaching approach.
Your answer
Provide a brief (75-100 word/1-2 sentences) description of the proposed session. This short description will be used in the conference brochure. *
Your answer
Describe the systems that your school has put into place to ensure that the accurate implementation of the practices outlined in the proposed session can and does occur. *
Your answer
Describe the data used to identify the status of current practice and evaluate the impact of the interventions or practices outlined in the proposed session. *
Your answer
Describe the practices in place to support students that are related to the topic of the proposed session. *
Your answer
Describe the outcome data that is available to support that the proposed session topic is having a positive impact on the social competence and/or academic achievement of students in your building. *
Your answer
Describe adult engagement strategies you will implement to keep participants engaged during your session:
Your answer
Primary Presenter Name *
Your answer
Primary Presenter Job Title *
Your answer
Primary Presenter Email *
Your answer
Secondary Presenter Name
Your answer
Secondary Presenter Job Title
Your answer
Secondary Presenter Email
Your answer
Statement of Intent
If this proposal is selected, my co-presenters and I agree to take part in the program and register for the conference. I understand that only one registration fee will be waived for each proposal that is accepted. I understand that it will be my responsibility to notify my co-presenters regarding the status of the proposal and the date, time, and location of the presentation. I understand that the conference organizers will provide a laptop, one screen, one microphone, and one table in each room; the presenter bears the responsibility for arranging any other audiovisual equipment required.
I understand and agree to the Statement of Intent *
Type initials here
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