Educational Support Services PreReferral Protocol

Date: ________________________
Student: ______________________

Teacher:______________________

Please check off the appropriate boxes:

1. Area(s) of concern:
Academic:
Social:

Numeracy

Peers

Other (please specify): _____________

Adults

Emotional: Anxious
specify):___________
Behavior:

Literacy

Withdrawn

Inattentive

Disruptive

Angry

Sad

Physical

Other (please
Verbal

Non-Compliant

Detailed descriptions of the top 3 areas of concern:

1.___________________________________________________________________________
2.___________________________________________________________________________
3.___________________________________________________________________________
2.

Data Collection/Review:
Review Cum File
Video

3.

Anecdotal Notes

Observation

Self-monitoring checklist

Consult with teachers (i.e. music, gym, prior teacher)

Start communication with parents

Vision Checked
Hearing Checked
Changes at home
Medical Issues

4.

Student Portfolio/Work

Date: ______________________

Date: ________________________
Date: ________________________
Details: ______________________
Details:_______________________

1st Problem Solving Meeting (PSM) Please place a copy in cum file.
Recommended reference for instructional, environmental and assessment strategies:
http://www.teachspeced.ca/index.php?q=splash

Educational Support Services PreReferral Protocol

5.

Implemented strategies from 1st PSM for 4-6 weeks.

6.
2nd PSM involving Resource, Administration, Guidance, Literacy Mentor and/or Math
Mentor.