Self-Assessment of MTSS Implementation (SAM) Name of Respondent: School/District: Individual Record of Responses Review the domains in the SAM instrument and consider where your school currently rates in terms of implementation. Once each team members’ responses are recorded, SAM Domains Item # select a facilitator to guide the team in reaching consensus regarding the level of MTSS started implementation. Optimizing Not 0 1 2 3 3. Communication and 3.17 SAM Domains Item # started Collaboration Domain 3.18 Optimizing Not (Items 17-20) 3.19 0 1 2 3 3.20 1.1 Domain Average: 4.21 1.2 1. Leadership Domain 4.22 4. Problem (Items 1-5) 1.3 4.23 Solving Domain 1.4 Domain Average: 4.24 (Items 21-27) 4.25 1.5 Domain Average: 4.26 2.6 4.27 2.7 5.28 5 Three Tiered 2.8 5.29 2. Building the Instruction/Intervention 5.30 Capacity/Infrastructure 2.9 Domain 5.31 for Implementation 28-33) 2.10 5.32 Domain 2.11 Domain Average: 5.33 (Items 6-16) 2.12 6.34 6. Data Evaluations Domain Average: 6.35 2.13 Domain 6.36 2.14 (Items 34-39) 6.37 2.15 6.38 Domain Average: 6.39 2.16
Self-Assessment of MTSS Implementation (SAM) Individual Record of Responses Review the domains in the SAM instrument and consider where your school currently rates in terms of implementation. Once each team members’ responses are recorded, select a facilitator to guide the team in reaching consensus regarding the level of MTSS implementation. SAM Domains Item # Not started Optimizing 0 1 2 3 1. Leadership Domain (Items 1-5) Domain Average: 1.1 1.2 1.3 1.4 1.5 2. Building the Capacity/Infrastructure for Implementation Domain (Items 6-16) Domain Average: 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 2.15 2.16 Name of Respondent: School/District: SAM Domains Item # Not started Optimizing 0 1 2 3 3. Communication and Collaboration Domain (Items 17-20) Domain Average: 3.17 3.18 3.19 3.20 4. Problem Solving Domain (Items 21-27) Domain Average: 4.21 4.22 4.23 4.24 4.25 4.26 4.27 5 Three Tiered Instruction/Intervention Domain 28-33) Domain Average: 5.28 5.29 5.30 5.31 5.32 5.33 6. Data Evaluations Domain (Items 34-39) Domain Average: 6.34 6.35 6.36 6.37 6.38 6.39
JE-SAM-Individual-Record.docx