Sedgefield Middle School Monitoring Form

Student:
School: Sedgefield Middle School
W1 W2 W3 W4
CHECK
Academic data
Block 1: English
Number of D's or F's
Number of Missing Assignments
Block 2: History
Number of D's or F's
Number of Missing Assignments
Block 3: Elective
Number of D's or F's
Number of Missing Assignments
Block 4: Math
Number of D's or F's
Number of Missing Assignments
Behavior Data
Block 1: English
Tardy
Absenses
Behavior Infractions
OSS/ISS
Block 2: History
Tardy
Absenses
Behavior Infractions
OSS/ISS
Block 3: Elective
Tardy
Absenses
Behavior Infractions
OSS/ISS
Block 4: Math
Tardy
Absenses
Behavior Infractions
OSS/ISS
CONNECT
Communication
 Formal
With Student
Informal
Attempt/not reached
Left message
Note home
With family
Phone conversation
Meeting
Home visit
Communication with school staf
Communication with outside agency
Basic intervention
Share "check" data
Provide regular feedback
Discuss staying in school
Problem solve about risk
Intensive intervention
Facilitate goal setting

Discuss academic progress and supports

Discuss behavior and supports

Discuss how current choices impact likelihood
of graduating from high school

Intensive problem solving

Intensive problem solving with parent

Intensive problem solving with school
personnel

Facilitate participation in community service

Facilitate participation in school or community
sponsored activities

Facilitate tutoring
Facilitate participation in small-group
instruction for passing exit exam

Teach problem solving skills

Teach organization and study skills

Arrange an alternative to suspension

Other: ________________
 Monthly summary of case notes
Date: Notes:
Goal: Attendance
Engagement
Investment in future
Date: Notes:
Goal: Attendance
Engagement
Investment in future
Date: Notes:
Goal: Attendance
Engagement
Investment in future
Date: Notes:
Goal: Attendance
Engagement
Investment in future
Date: Notes:
Goal: Attendance
Engagement
Investment in future
Date: Notes:
Goal: Attendance
Engagement
Investment in future

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Check & Connect mentors may use (and/or modify) this form for students at their site.
 ID #:
Mentor:
W5 W6 W7 W8 W9
Grade:
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