Name of School

Exemplar Application PowerpointDate: (School Year: YYYY/YYYY)

Summer Contact Name : Summer Contact Phone Number:

Revised NC PBIS 10-25-2013

PBIS Team Coach, with contact information Team members

List with role within PBIS team (Ex: Data analyst)

List position at school (Ex: 7th grade teacher)

Demographics

Name of school, LEAAddressPhone Number (Area) ###-####CountyRegion

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

Tier 1 ImplementationComponents 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

Tier 2 Implementation

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

Tier 3 ImplementationComponents 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

Outcome Data: Demonstrate Improvement in BOTH Academic and

Behavior Indicators 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

Outcome Data: Demonstrate Improvement in ONE of the following:

EBS Self-Assessment (pbisapps) Staff Retention data Climate surveys

Teacher Working Conditions YRBS (Youth Risk Behavior Survey) School-created climate survey

Special Education Referral Information Attendance rates

Integration of Initiatives (optional)

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

District Implementation(optional)

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