RENEW Intent to Participate, School Profile and Readiness Form

RENEW Intent to Participate, School Profile and Readiness Form

RENEW Intent to Participate, School Profile and Readiness Form

Training, technical assistance, and support provided by

Pennsylvania Training and Technical Assistance Network (PaTTAN)

Date form Completed:


School District/Agency Name: Entity:

School Building: Intermediate Unit # (if applicable):


Name / Phone / Email
(or primary administrator):
Assistant Principal:
(or primary discipline person):
Director of Special Education:
Supporting RENEW TOT:
1. At-risk indicators for the previous school year: / Number / Percentage of total # of students / Data Not Available (N/A)
Students who dropped out of your school
Students who were suspended for 20 days or more
Students who were truant for 20 or more days
Students who failed 3 or more classes during school year
Students with IEPs who dropped out of your school
Students with IEPs who were suspended for 20 days or more
Students with IEPs who were truant for 20 days or more
Students with IEPs who failed 3 or more classes during school year

2. Your school’s AYP status level for the last academic school year: (select one from the drop down menu)

  1. Please describe any areas in which your school has concerns based on issues of disproportionality (cite data where applicable):


Effective multi-tiered model implementation requires the development of teams to address at-risk student needs. This project requires your school to develop a Tertiary Level Planning Team to ensure that RENEW and other tertiary level supports and practices are implemented in your school. As part of this application, you agree to:

  • Identify and support both staff members and, to the maximum extent possible, community providers to work in concert with your school’s RENEW Facilitator(s)*.
  • To support to no less than1 student per RENEW Facilitator* during the 2015-16 school year.
  • To make available the time needed for training and meeting of a Tertiary Level Planning Team that will oversee the development and implementation of Tertiary student supports, such as REWEW.

An essential element of effective multi-tiered systems change intervention in a school is the designation of a “building coach” (or RENEW Facilitator*). The RENEW Facilitator is the primary person or persons who will guide and promote the project implementation process in your school. Your school’s RENEW Facilitator will be facilitating the RENEW Process and should expect to participate in up to 4 full days of RENEW training during the upcoming academic year. Your RENEW Facilitator(s) will need to be a member of the school’s Tertiary Level Planning Team.

  1. Who will be the RENEW Facilitator(s) for your school? You may designate anywhere from one to three RENEW Facilitators for your school.

Name / School Role / Phone / Email
  1. In addition to RENEW facilitators, please list additional staff who will be members of your Tertiary Team.

Name / School Role / Phone / Email
  1. Of the staff listed above, please list who your designated RENEW Building Coach will be:

Name: Email:

Part 4: COMMITMENTS (To be completed by a Building or District Administrator)

1. / Is your school implementing PBIS? / Yes / No
a / If YES, does your school have universal and secondary levels of social and behavioral supports in place? Please explain if necessary: / Yes / No
2. / Does your school support the development and implementation of individualized school to career support and services for all students? / Yes / No
3. / Have your Director of Special Education, special education staff, counseling staff, and other key staff been involved in the development of this application and are they aware of the project commitments? / Yes / No
4. / Will your staff actively participate in the process of identifying, referring to, and collaborating with the RENEW Facilitators to provide RENEW intensive planning and support services to youth with significant support needs? / Yes / No
5. / To make certain that participation in this project aligns with and will contribute to your existing and planned school priorities and initiatives, please indicate your school’s readiness by responding to the following statements:
The development of a Tier 3 support system and RENEW services will be one of our top school initiativesand will receive major attention and focus at the building level. / Yes / No
We have reviewed our school’s improvement plan and assessed our priorities. We believe that our top priorities align with the implementation of RENEW in our school. / Yes / No
The following current initiatives are in place in our school and align with the project’s goals and activities
(please list – detail is not necessary):
The school’s administrator endorses the RENEW initiative and is committed to active involvement, including participating on the Tertiary Level Planning Team. / Yes / No
The school district’s superintendent or designee has reviewed this application, signed it, and is committed to supporting this initiative over the multi-year process. / Yes / No
6. / While all the training, technical assistance, and support services for RENEW will be provided by PaTTAN, the school administrator and the district superintendent understand that some incidental costs will be absorbed by the school district (i.e. substitute teachers for team members to attending trainings). / Yes / No
7. / The school’s Tertiary Level Planning Team will recognize, understand and develop a strategy for connecting and not duplicating other system processes such as High Fidelity Wraparound, Family Group Decision Making and others. If other processes exist, the planning team will include the other systems or defer to them as the method for planning for at-risk students. Moreover, a member of the planning team will be available to participate within the other systems’ process to assure the educational needs of students are met. / Yes / No
8. / The school will utilize a data-based system for inputting and analyzing student specific and program information / Yes / No
9 / If site is not affiliated with an Intermediate Unit, site has identified and allocated time for an individual to serve as the RENEW building level coach. / Yes / No
Part 5: RENEW READINESS (Adapted from RENEW Readiness Checklist, J. Malloy 2012)

Effective and sustainable implementation of a multi-tiered system of school-wide change requires the district’s support associated with a systematic approach to student discipline and school climate. Please self-assess the degree to which each of the following is in place:

Question / Current Level of Implementation / Priority
In Place (2) / Partially in Place (1) / Not in Place (0) / High / Medium / Low
1 / The district is committed to providing appropriate, evidence-based interventions to improve outcomes for all high school students.
2 / The school/agency prioritizes the provision of flexible services to ensure the success of all youth
3 / A systematic process was used to identify youth who need individualized planning and supports or for youth who did not respond positively to other interventions.
4 / A team based problem-solving process is being promoted throughout the district and school levels.
5 / All youth who meet the level of need for RENEW are referred for RENEW services.
6 / The school/agency has the capacity to provide behavior support and interventions to youth before being referred for intensive services.
7 / The school/agency administration provides ample time and resources to allow staff to receive training and coaching and to implement RENEW services with fidelity.
8 / The school/agency has designated a point person and several staff members who have been trained in and provide individualized RENEW services.
9 / The school/agency embraces and demonstrates a commitment to facilitate and respond to student-led plans, including student-led IEPS or service plans.
10 / The District has a good relationship with community and child serving system (Child Welfare, Juvenile Justice, Behavioral Health (Drug and Alcohol/Mental Health Services)
11 / The district’s special education team supports the development of individualized and flexible pathways to graduation for students with disabilities.
12 / The school/agency is welcoming to and collaborates with family and community members at all organizational levels.
13 / The district commits to ensure staff can participate in and sustain RENEW activities.
14 / The school/agency embraces a philosophy of and has policies and procedures that support “unconditional care,” when providing individualized services to youth
Question / Current Level of Implementation / Priority
In Place (2) / Partially in Place (1) / Not in Place (0) / High / Medium / Low
15 / A multi-tiered system for school and district-wide reform is one of the top District Improvement Plan goals.
16 / Discipline data is collected, analyzed, shared and used for decision-making at the building and district level.
Readiness or Implementation Score / Total number of points = / 34 = %

RENEW Implementation Action Plan

Choose the items in the checklist that are marked “High Priority” or “Not In Place” and develop action steps for those items.

Activity / Activity Task Analysis (What) / Who / By When

The following signatures of the school’s administrators, in addition to the district’s director of special education and the school district’s superintendent will indicate that this application has been completed and reviewed for accuracy:

School Principal: Date

Director of Special Education Services: Date

Superintendent/Designee/Director: Date

For questions, please contact:

Karen Grammas

6340 Flank Drive
Harrisburg, PA 17112


Mike Minor

PaTTAN Pittsburgh

3190 William Pitt Way
Pittsburgh, PA 15238

800-446-5607 x6863

Sielke Caparelli

PaTTAN Pittsburgh

3190 William Pitt Way
Pittsburgh, PA 15238

800-446-5607 x6863