Functional Behavioral Assessment and Behavior Intervention Plan Resources and Forms

• ABC Form
• Alternative ABC Form - Blank Form (Created by Robyn Jeppson)
• Alternative ABC Form - Blank Microsoft Word Form (Created by Robyn Jeppson)
• Behavior Observation Form
• Escalation Map Based off Safety Care
   
• FBA-BIP Fillable Word Document Template 2017
• (Please save final FBA-BIP forms for students on MyIDEA)
• Old FBA-BIP forms

Least Restrictive Behavior Initiative (LRBI)

• LRBI Guidelines
• Emergency Safety Intervention: Procedures -- Emergency Safety Interventions:  Time-Out and Physical Interventions (.pdf) - 2017

Emergency Contact

• Emergency Contact Q & A
• Emergency Debriefing Contact Form (Updated November 2018)

Manifestation Determination

• Manifestation Determination (fillable PDF)
• Manifestation Determination (fillable Word document)

Transportation and Bus Safety for Students with Disabilities

• Emergency Contact Form Suggestions
• for Fading Bus Safety Harness

Web Based Resources

• Survey Level Assessment Page
• Chart Dog
• Instructional Programs for Students with Disabilities

ABC Observation Forms

• ABC Form - Physical and Verbal Aggression (Created by Robyn Jeppson)
• ABC Form - Blank Form (Created by Robyn Jeppson)
• ABC Form - Blank Microsoft Word Form (Created by Robyn Jeppson)

Data Collection Forms and Tools

• Duration and Intensity Observation Form
• SLD Classroom Observation Forms
• On Target (Created by Marcia Oman)

Excel Goal Tracker Data Sheets

• Goal Tracker - Increasing Skill (Percentage Scale) -- for use when tracking a skill that the student needs to increase, based on a percentage.
• Goal Tracker - Increasing Skill (4 Point Scale) -- for use when tracking a skill thatthe student needs to increase, based on a 4-point scale.
• Goal Tracker - Increasing Skill (6 Point Scale) -- for use when tracking a skill that the student needs to increase, based on a 6-point scale.
• Goal Tracker - Increasing Skill (Adjustable Scale) -- for use when tracking a skill that the student needs to increase, where the max level may not be set at a common number (i.e. fluency, hand raises, etc.).
• Goal Tracker - Decreasing Skill (Percentage Scale) -- for use when tracking a skill that the student needs to decrease, based on a percentage.
• Goal Tracker - Decreasing Skill (Adjustable Scale) -- for use when tracking a skill that the student needs to decrease, where the max level may not be set at a common number.
• Goal Tracker - Decreasing and Increasing Skills (Adjustable Scale) -- for use when simultaneously tracking a behavior to decrease and a related behavior to increase (i.e. talkouts v. hand raises).
• Goal Tracker - Two Increasing Skills (Adjustable Scale) -- for use when simultaneously tracking two related behaviors that the student needs to increase.
• Goal Tracker - Two Decreasing Skills (Adjustable Scale) -- for use when simultaneously tracking two related behaviors that the student needs to decrease.

Other

• Regular Education Interventions/At-Risk Documentation Sample Form (.docx)

Vision Symptoms Questionnaire (.pdf) - "If the team decides that an updated screening is needed then they must get permission for vision on the Special Education consent form and then fill out the Symptoms Questionnaire and give to the nurse.

If it is a student in 2, 4, 6, 8, 10, 11, or above, the team must decide if a vision screening is needed to rule out a vision concern. A team can review the past years screenings in Encore under Medical, Medical screenings. You might need your LEA to help review these. 

1. If the team decides that no new screening is needed, then they must make sure the last vision screening date and results are listed on the top of the data review and Eligibility form. 
2. If the team decides that an updated screening is needed, then they must get permission for vision on the Special Education consent form and then fill out the Symptoms Questionnaire (found on the nursing webpage) and give to the nurse. The nurse may decide to refer to the doctor and that is the results that should show up on the top of the Eligibility form.  

Extended Year Additional Pay for Special Educators

Please note – DO NOT USE THE TIME CLOCK SYSTEM in Encore. Paper TIMECARDS ARE STILL USED FOR LEGISLATIVE DAYS.

• Explanation of Extended Year Option - updated 7-7-2022 (.pdf)
• The survey needs to be completely filled out. (no longer available)  This includes the dates worked, what type of work was done, etc.  When it prompts you for the name and email address of the approving administrator, correctly enter it as "Meridee Litster -- MLITSTER@DSDMAIL.NET" (Check to ensure it's spelled correctly).
• FALL 2023 Eligible Work Days: 7/31 to 8/11, 2023
• SPRING 2024 Eligible Work Days: 6/3 to 6/14, 2024
• If the June 14, 2024, deadline for Time Card submission is missed, you will not get paid.
• PDF - Federal Timecard (Fillable)

How can they be used? Extended days CAN be used for: 

• IEP related duties, 
• record maintenance,
• file preparation,
• report preparation,
• assessment related duties,
• conferring with parents,
• and other paperwork related to the implementation of IDEA. 

Extended days may NOT be used for:

• professional development, instructional planning, classroom setup/teardown, or direct student instruction.

USBE's Extended Year for Special Educators (R-277-525) for SPED teachers, Vision Specialists, Hearing Specialists, Adapted PE Teachers, SLPs and SLTs ONLY.

• Do not use the Encore Time Clock for this.  You will use a timecard.
• Sample Extended Year Timecard for Special Education Teachers, Vision Specialists, Hearing Specialists, Adapted PE Teachers and Speech-Language Pathologists - Incorrect timecard completion will result in delayed payment (by up to 6 months because EY is only paid in September and June.)
• If the June 14, 2024, deadline is missed, you will not get paid.

Eligible workdays:

• July 31, 2023 to August 11, 2023
• June 3, 2024 to June 14, 2024
• If the June deadline is missed, you will not get paid (see explanation above).

Extended School Year (ESY)

• Simplified and Revised Regression Formula Checklist (.pdf)
• ESY Anecdotal Form (Retrospective and Predictive Data) - (.pdf)
• ESY Eligibility Determination and IEP are on myIDEA (link)

File Compliance and Transfer Procedures

Notice: (Soft Closure) 2020 End of Year File Transfer Protocol for Resource Students (.pdf)

• Current Student Information - obtain from myIDEA or contact your TCM.
• Order of File for Davis School District (.pdf)
• File Cabinet Access List (.pdf)
• Record of Access for Student's File (attach to inside of front cover of permanent record) (.pdf)
• Received Label (.pdf)
• Annual Disclosure of Parent/Guardian Consent to Email Special Education documents & other correspondence (.pdf) | Spanish Version (.pdf)

• TCM Compliance Checklist (.pdf) revised 10-2021

2021-22 File Transfer Procedures and Responsibilities (.pdf)

• 6+1* Reasons to Return a File for Compliance Errors (.pdf)
• School to School File Transfer Log (.pdf)
• Internal File Transfer Log (keep record of all transfers sent out of schools) - (.pdf)
• File Check Out Log (use to track files in the building)

Out of District File Transfer Policies

• Out of District File Transfer Procedures (requires access to PIE folder)
• Move-in Transfer procedures for Out of District and Out of State (requires access to PIE folder)
• Authorization for Release of Special Education Information
• File Transfer Request Form
• Release of Record Receipt Form

Preschool File Transfer Procedures

• 2017-18 Preschool to Kindergarten Transfer Procedures (.pdf)
• File Transfer Log
• Utah Preschool Outcomes Data (UPOD)

Making Changes to the IEP

DSD Technical Compliance Managers Webpage

Health and Medical Information

Authorization and Release of Health Information (.pdf)

Child Health and Developmental History

• English
• Spanish

Health Professional Report - The Health Professional Report supports teams in gathering the required medical history information. This form is NOT mandatory. A medical history might also be documented as a medical report and an evaluation summary from a private clinical setting. If there is documentation of prior medical history, specific syndromes (if applicable), health concerns and medications, the name and role of the medical provider and the date, it is a medical history.

• Letter to Medical Provider Regarding Medical History (.pdf)

See the Policy and Information Exchange (PIE) website for the Medical History Definition and Procedures (PIE folder log-in required)

Special Education Nurses' Forms

For the most up-to-date Nurses forms go to DSD Health and Nursing Services webpage - See the Secretaries and Teacher Resources tab for more information.

IEP Accommodations, Participation in State and Local Assessment
and IEP Progress Report Forms

• Dynamic Learning Maps (DLM) - Davis District Resources - (link)
• Utah Alternative Assessment Manual (.pdf)
• Utah Assessment Participation and Accommodations Policy (.pdf)
• PIE Folder for Assessment Participation (log in required) - (link)
• Accessing IEP Accommodations (Instructional and Assessment) from Encore - for General Education Teachers (.pdf)
• Accessing IEP Accommodations (Instructional and Assessment) from myIDEA - for Special Education Teachers (.pdf)
• Progress Report Cover - Use this as a cover page for graphs and other data sheets if you do not include a progress report from myIDEA. (.pdf)
• Alternative Form for Progress Report (.pdf)

Meeting Documents

DSD SPED Learning Plan 2020

• DSD SPED Learning Plan Folder, Materials, Video, etc. (PIE - Guidelines Folder)

Meeting Summary Options

• Fillable/Savable Meeting Summary - 2-page PDF (will not print horizontal lines for signatures only) - Updated 8/9/2018.
• Fillable/Savable Meeting Summary - Word Template (will re-size to fit contents as typed) - Updated 9/5/2018.
• Print Meeting Summary- 2-page PDF (prints horizontal lines for recording meeting events and signatures by hand) - Updated 8/9/2018.

Parental Procedural Safeguards

Procedural Safeguards & Guardian Notices Summary (updated July 2018) 
Spanish Version: Avisos y Garantías del Proceso del Padre/s o Tutor Legal 

Procedural Safeguards Document (updated November 2023)

• Spanish (2023 version)
• Other USBE Versions - Procedural Safeguards and Annual Parent/Guardian Notices (Child Find, Carson Smith Special Needs Scholarship, Destruction of Records, Medicaid Information) for Students with Disabilities and their Parents under the IDEA 2004. -- Revised November 2016 -- Translations for Navajo, Arabic, Somali, Spanish, Tongan, and Vietnamese are all available here. When you get to the page, click the sub tab entitled "Procedural Safeguards"

Other Documents

• Anecdotal Record (Not to be used as a meeting summary document.)
• Annual Disclosure of Parent/Guardian Consent to Email Special Education documents & other correspondence (.pdf) | Spanish Version (.pdf)
• Consent to Involve Outside Agencies in IEP Meetings (.pdf) | Spanish Version (.pdf)
• Regular Education Interventions/At-Risk Documentation Sample Form (.docx)

Special Education Support Personnel Observation Form (fillable PDF) | Spanish (fillable PDF)

Off Campus Community Access:

• Travel Plan - Fillable (.pdf)
• Procedures (.pdf)
• Support Items (.docx)
• Example Transition Checklist (.docx)

Support Teams and Other Referrals

Support Teams

Support Team Webpage - Click here to access the current referral link

Other Referrals

Adapted PE Referral
Occupational Therapy Referral - Please contact the OT that serves your school for support.
Physical Therapy Referral

Transition and Graduation

• Notice of Transfer of Parental Rights at the Age of Majority (fillable/savable PDF)
• Consent to Involve Outside Agencies in IEP Meetings
• Graduation Exit Summary is now available in myIDEA
  • Alternative Form - Graduation Exit Summary (.pdf)
• Credit Tracking Tool

Special Education/504 Transportation Needs Request (.pdf)