Ceis Documentation Form For Success Class
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1South Bend Community School Corporation
Special Education Department
CEIS Documentation Form for SUCCESS Class
(Coordinating Early Intervention Services)
Students listed below were assigned to my SUCCESS class from ____________________ to ________________
(Beginning Date)
(Ending Date)
Each Success period is _______________ minutes daily.
Please list ONLY GENERAL EDUCATION students who have been identified as At Risk. (DO NOT INCLUDE
THOSE RECEIVING SPEECH THERAPY)
Academic or
How was At-Risk
Strategies used (Number
Name
STN
Grade
Behavioral?
Identified?*
from below)
*Examples include: M-Class/Acuity Scores, SAT team referral, office referrals, behavior plan (NOT Special Ed BIP)
Signature of Teacher: ___________________________________ School: _____________________________
List or check the strategies you are implementing with the above named students:
Academic Strategies
Behavioral Strategies
1.
Flexible groupings
19. Non verbal cues
2.
Hands-on activities
20. Behavior tracking checklist
3.
Pre-teach concepts
21. Verbal warnings
4.
Extra Examples
22. Visual reminders/cues
5.
Read aloud text
23. Behavior contract
6.
Use of graphic organizers
24. Close physical proximity
7.
Provide material at instructional level
25. Allow choices
8.
Assign fewer items
26. Student works for specified reward________
9.
Provide writing supports/prompts\
27. Review expectations prior to transitions
10.
Reduce copying requirements
28.
___________________________________
11.
Allow the use of a textbook or visual chart
29.
___________________________________
12.
Repeated Readings
30.
___________________________________
13.
Paired/Partner Readings
31.
___________________________________
14.
Story Mapping
32.
___________________________________
15.
WilsonLips
33.
___________________________________
16.
___________________________________
34.
___________________________________
17.
___________________________________
35.
___________________________________
18.
___________________________________
36.
___________________________________
2/14/14
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