"Behavior/Performance Review Results Form - School District of Philadelphia"

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BEHAVIOR/PERFORMANCE REVIEW RESULTS
Student Name:
ID#:
School:
Date:
I.
DECISION
The Behavior/Performance Review Team responded to the following four statements after reviewing the student’s academic and behavioral data
listed below.
1. The student’s academic performance and/or behavior is significantly interfering with his/her learning, indicating s/he may need a Multi-Disciplinary
Evaluation (MDE).
Yes
No
2. The student’s history of academic performance and/or behavior indicates that the student may need a Multi-Disciplinary Evaluation (MDE).
Yes
No
3. There is previous evidence of verbal or written expression of concern from parent/surrogate parent and/or teachers that the student may have a disability.
Yes
No
4. The parent/surrogate parent has requested a Multi-Disciplinary Evaluation PRIOR TO DISCIPLINARY INCIDENT.
Yes
No
 If the response to ANY of the above statements is YES, then the BPR team has decided that the student is thought to have a disability. Child will remain in
current placement until the evaluation is completed.
.
If the response to ALL of the above statements is NO, then the BPR team has decided that the student is NOT thought to have a disability
II.
CUMULATIVE RECORDS REVIEWED
Yes
No
Not Available
Pink Slips
Suspensions
Lateral transfers (EH 21) and Alternative Educational Settings
Report card student conduct rating:
Report card grades and last documented reading level
Documentation of verbal/written expression of concern from Parent/Surrogate Parent and/or teachers that the student may have a
disability:
TerraNova and PSSA results
MTSS Log: Behavioral and academic Interventions
Attendance/Lateness/Truancy history:
Student history with special education process
Conversations with current and past teachers
Conversations with parent/surrogate parent:
1 of 2
School District of Philadelphia
Behavior/Performance Review
OSR-7 (Rev.8/2013)
BEHAVIOR/PERFORMANCE REVIEW RESULTS
Student Name:
ID#:
School:
Date:
I.
DECISION
The Behavior/Performance Review Team responded to the following four statements after reviewing the student’s academic and behavioral data
listed below.
1. The student’s academic performance and/or behavior is significantly interfering with his/her learning, indicating s/he may need a Multi-Disciplinary
Evaluation (MDE).
Yes
No
2. The student’s history of academic performance and/or behavior indicates that the student may need a Multi-Disciplinary Evaluation (MDE).
Yes
No
3. There is previous evidence of verbal or written expression of concern from parent/surrogate parent and/or teachers that the student may have a disability.
Yes
No
4. The parent/surrogate parent has requested a Multi-Disciplinary Evaluation PRIOR TO DISCIPLINARY INCIDENT.
Yes
No
 If the response to ANY of the above statements is YES, then the BPR team has decided that the student is thought to have a disability. Child will remain in
current placement until the evaluation is completed.
.
If the response to ALL of the above statements is NO, then the BPR team has decided that the student is NOT thought to have a disability
II.
CUMULATIVE RECORDS REVIEWED
Yes
No
Not Available
Pink Slips
Suspensions
Lateral transfers (EH 21) and Alternative Educational Settings
Report card student conduct rating:
Report card grades and last documented reading level
Documentation of verbal/written expression of concern from Parent/Surrogate Parent and/or teachers that the student may have a
disability:
TerraNova and PSSA results
MTSS Log: Behavioral and academic Interventions
Attendance/Lateness/Truancy history:
Student history with special education process
Conversations with current and past teachers
Conversations with parent/surrogate parent:
1 of 2
School District of Philadelphia
Behavior/Performance Review
OSR-7 (Rev.8/2013)
Student Name:
ID#:
School:
Date:
III.
ACTION - The result of the Behavior/Performance Review (BPR) is that:
1. The BPR Team has determined that the student is thought to have a disability. Results shall be shared with parent/surrogate parent.
Team will issue Permission to Evaluate immediately to the parent/surrogate parent and expedite the MDE. Child will remain in current placement,
UNLESS AN ACT 26 OFFENSE WAS COMMITTED.
2. The BPR Team has determined that the student is thought NOT to have a disability.
Results shall be shared with the parent/surrogate parent and the disciplinary action shall proceed.
3. Post disciplinary incident, the parent/surrogate parent expressed concern in writing that the student may have a disability and/or requested an
evaluation, but the BPR team has answered NO to all statements in Section I of this form. Team will issue Permission to Evaluate immediately and
refer the BPR to the Disciplinary/Truancy Liaison for disciplinary action.
MEMBERS OF THE BPR TEAM included those who have signed below.
SIGNATURE
NAME
TITLE/ROLE *
DATE SIGNED
Mandatory Members
Principal or Designee*
School Counselor*
Student’s Teacher*
Staff Representative (at Student’s
request*)
Regional BPR Monitor*
Special Education Liaison
(optional)
CHECK ALL THAT APPLY:
Yes
No
• BPR Results were shared with Parent/Surrogate Parent.
Signature of Transmitter _________________________
Date
Method of Transmission:
meeting
telephone
mail
fax
other (specify)
Yes
No
• Permission to Evaluate sent to Parent/Surrogate Parent
Principal/Designee Signature _____________________
Date
Yes
No
• Copy of BPR Results to Pupil Pocket
Principal/Designee Signature _____________________
Date
2 of 2
School District of Philadelphia
Behavior/Performance Review
OSR-7 (Rev.8/2013)
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