8/13/17

Tomball Independent School District

Department of Special Services

Community Based Instruction (CBI) Procedures

Definition

Community Based Instruction is the process of having students practice the critical skills

needed for the future in community settings. This is different than a “field trip” in that it is

instructional and an integral part of the student’s Individual Education Plan rather than an

experiential trip for pleasure. Goals are written such that skills learned in the classroom

can be generalized to the community setting or an activity being taught in the classroom

requires the student to go into the community as part of the instruction.

Purpose

The purpose of a CBI is to provide real life instruction in the community in which the

student resides. Students with disabilities often need not only instruction in the classroom

but experiences in the community to reinforce those skills taught.

Examples

Students may need to practice the making of a meal as part of their daily living class. As

part of this instruction, the students would plan a menu, make a grocery list of items

needed, compute the amount of money needed for the purchases, go to the grocery store in

the community to purchase the items needed and then cook the meal in their classroom

setting. These are real functional activities students require to be independent in the

future.

Other students may have difficulty learning to order food at a restaurant. The teacher

would begin this type of activity by gathering menus and samples of materials from the

restaurants, practice ordering from the menus in the classroom and then go to the

restaurant in the community for their Community Based Instruction.

Developmental/SLL/PALS Curriculum

Tomball ISD Developmental/SLL/PALS classrooms utilize the Unique Learning Skills

curriculum to address the academic and functional needs of students with disabilities.

Students must have curriculum aligned goals and objectives in areas of need to be

addressed on community based instruction trips. The following areas should be addressed:

functional reading, functional writing, functional math, domestic skills, community skills,

communication, behavior, pre-vocational skills, vocational skills, recreational skills, and

leisure skills.

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General Guidelines for

Community Based Instruction

Guidelines:

4 trips per class allowed each year.

All CBI trips must be completed by the first Friday in May.

CBIs are intended to be an extension of the classroom. Adequate teaching time (no fewer than

3 weeks) must occur prior to the trip. You may not use all 4 allowed CBI trips in the spring

semester. They must be thoughtfully planned throughout the year.

Must be directly linked to IEP goals and objectives.

Must include lesson plans and activities to prepare students for the upcoming CBI trip.

Must be approved by the campus administrator and submitted to Sharon Meanor at Special

Services 4 weeks prior to the trip date. Please submit the following forms:

“Notification of Off Campus Activity” form

“CBI Trip Request” form

TISD Co-curricular / Extracurricular Trip (sent home with parents)

Sharon Meanor will notify you by e-mail of trip approval.

Students should never be told of a trip until the request has been approved.

CBIs are instructional and therefore should not be used as rewards or punishment.

CBIs are instructional and should be attended by TISD staff and students only. Rare

exceptions can be made to allow parents of students to attend, but must be cleared by campus

administrator and Program Specialist for Low Incidence Populations first.

All CBI trips should have adequate adult supervision. Please be certain ratios correspond to

staff:student ratio on the AU supplement for students with autism.

Students from other classes may not participate in the CBI unless it directly relates to the

student’s IEP and prior approval from the campus administrator is obtained.

CBIs do not have to be attended by all students in the developmental/SLL/PALS classes. If it

is appropriate for some students to attend the trip and others to stay at the campus based on the

targeted goals, staff must be arranged to assist with the needs of all the students.

Staff members must not invite personal friends or family members to meet them on the trip.

A TISD staff member should NEVER ask the driver to take the group somewhere other than

where they are authorized and approved to go.

Cell phones are used for emergencies and teacher contact on CBI trips.

Money:

Special Services will reimburse $3 per student per trip. Money can be used on each trip or

split among multiple trips. (For instance: 10 students x $3.00 x 4 trips = $120 per year)

Submit signed receipts of the student lunches only to Sharon Meanor for reimbursement.

Adult lunches or snacks may not be paid for from the CBI fund.

Students may not bring any personal money on the trip.

Funds for CBIs will begin in October.

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Nurses:

A nurse is required to attend the trip for students who receive emergency medication for

seizures, multi-dose vial of epinephrine, or any other emergency situation.

Notify campus nurse 4 weeks prior to trip.

Campus nurse notifies Cathy Pool to arrange substitute nurse.

You must make note for a nurse on the “Notification of Off Campus Activity and CBI trip”

request form submitted to Special Services.

Nurses are paid for by Special Services.

Safety:

Each student must have an ID badge attached to or on his/her person that provides important

information (i.e., name, school, school district, teacher phone number).

Staff members should have a picture of each student with them in case of emergencies.

Staff members should have walkie-talkies or cell phones to make communication more

efficient.

Teachers should provide the campus receptionist/secretary with a cell phone number he/she

can be reached at on the trip in case of emergencies.

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TOMBALL INDEPENDENT SCHOOL DISTRICT

Department of Special Services

COMMUNITY-BASED TRIP REQUEST

(Must be attached to the TISD Transportation triplicate form)

School: _____________________ Date submitted:_____________________

(at least 4 weeks before trip)

Teacher: ____________________ Mileage: __________________________

(one-way from your campus)

Destination(s): _____________________________________________________________

Date of trip: ___/___/___ Departure Time: _______ Return Time: ________

Number of Students: _____ Number of Staff: _______ Nurse Needed: ______

Lift bus? Yes ____ # of wheelchairs ____ No ____

Community-Based Trip Objectives (related to student goals and objectives):

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

What criteria will be used to evaluate the progress of the student?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Comments:

_____

____________________________________

Approval: ___________________________ ________________________________

Principal Director of Special Services

Date Received: _ Date teacher notified of approval:

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Notification of Off-Campus Activity Complete and submit to campus administration at least one day prior to community-based instruction trip.

Classroom Teacher(s) Date Time off campus Locations and approximated times:

Students who will be off campus

Who will be driving the bus(es)? District driver(s) provided by transportation Classroom driver(s). List name(s).

Paraeducators who will be on the trip:

Nurse required to attend the trip to attend to the nursing needs of the following students:

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Parent Notification of Community Based Instruction

Teacher

Date of Trip

Time of Trip

Location(s)

The purpose of this trip is to

Each student should bring We will be working on the following skills; which will be individualized based on your student’s skills and IEP objectives (not every student will be working on all of the skills listed below):

Math

Reading

Social Skills

Language

Daily Living

Community Living

has my permission to participate in this CBI trip. I understand that students will be transported on a bus by a certified driver. has my permission to be photographed while participating on this trip, should the

opportunity arise. I understand these photographs may be used for school-related activities.

Parent/Guardian Date

8/13/17

Notificación a los padres - Instrucción basaba en la comunidad (CBI)

Maestro

Fecha del paseo

Hora del paseo

Lugar(es)

El propósito de este paseo es

Cada alumno debe traer Trabajaremos en las siguientes destrezas; las cuales serán individualizadas basándose en las destrezas de su hijo y los objetivos del IEP (no todos los alumnos trabajarán en las destrezas enumeradas a continuación:

Matemáticas

Lectura

Destrezas sociales

Lenguaje

Destrezas de la vida diaria

Vida en la comunidad

tiene mi permiso para participar en este paseo del programa CBI. Entiendo que los alumnos van a ser transportados en autobús por un conductor certificado. tiene mi permiso para ser fotografiado durante su participación en este paseo, si se presentara la oportunidad. Entiendo que estas fotografías podrían usarse para actividades relacionadas con la escuela.

Padre/Tutor legal Fecha

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TOMBALL INDEPENDENT SCHOOL DISTRICT

CO-CURRICULAR/EXTRACURRICULAR TRIPS Date

Dear Parent/Guardian: Your child has the opportunity to participate in an event that will take him/her off campus. To be able to do this, you must complete the form below and return it to the classroom teacher no later than . It must be completed and signed before your student will be allowed to travel.

Student Name (PRINT)___________________________________________________________ _Grade___________ Date of Birth:________ _____ Male/Female (circle one) Campus______ _____ Home Phone_______ _________ Second Father/Stepfather: _____________________________________Work #___________ ________Number______ _ Second Mother/Stepmother: ___________________________________Work #___________ ________Number________ _ Alternate Emergency Contact: ___________________________Phone #________________ ___Relation_____ _

Medical Information about student: Insurance Provider _________________ ___________________________ Policy Number____________ __________ Existing medical condition/s: _________________ ___________________________________________________ Date of most recent __________________________________________ ________________________Tetanus/Td Booster: _______ Allergies: _________ ____________________________________________________________________________ Medication/s taken routinely: ____________________ ___________________________________________ Special considerations: ____________________________________________________________________ ___ ====================================================================================

My child, (Print name)________ _____________________________, has

my permission to participate in the following activity:

Transportation by: From Date Leaving: Time Leaving: (Location)

To

Date Returning: Time Returning: (Location)

Please be prompt in picking up your returning student.

Additional Instructions from sponsor:

Name of Sponsor

I, the undersigned, do hereby authorize officials of the Tomball I.S.D. to contact persons named on this sheet in the event of illness, injury and/or inappropriate behavior of my child. If I or persons named on this sheet cannot be reached, T.I.S.D. school officials are hereby authorized to take whatever action is deemed necessary in their judgment, for the health and safety of said child. I realize that this form does not abrogate or modify my rights as a parent/guardian of a minor. I have voluntarily signed this form to facilitate and expedite the treatment of my child. I will not hold the Tomball I.S.D. or the school official(s) financially responsible for the emergency care and/or transportation of said child. _______________________________ ______________________________________________________

Date Signature of Parent/Guardian

8/13/17

DISTRITO ESCOLAR INDEPENDIENTE DE TOMBALL VIAJES EXTRA-CURRICULARES

Fecha: Estimados padres/guardianes: Su hijo/a tiene una oportunidad de participar en un evento que lo/la llevará fuera de su escuela. Para poder hacer esto, usted debe completar la forma de abajo y regresarla al coordinador del evento antes del . La forma debe estar completa y firmada para que su hijo/a pueda participar. Nombre del alumno ________________________________________________________________________Grado______________ Fecha de nacimiento:___________Masculino/ Femenino (circule uno) Escuela___________ Teléfono de la casa_________________ Padre/padrastro: _____________________________________Trabajo #___________________ Segundo Número________________ Madre/madrastra: ____________________________________Trabajo#____________________ Segundo Número_______________ Contacto de emergencia: ______________________________Teléfono #___________________ Relación______________________ Información médica sobre el alumno: Companía de suguro médico _________________________________________ Número de póliza____________________________ Condiciones médicas existentes:_________________________________________________________________________________ ______________________________________________________ Fecha de la última vacuna de Tétanos/Td Booster: ___________ Alergias: ____________________________________________________________________________________________________ Medicinas de rutina: __________________________________________________________________________________________ Consideraciones especiales: _____________________________________________________________________________________ ===================================================================================== Mi hijo/a, (Imprima)_____________________________________, tiene permiso para participar en la siguiente Costo por actividad: estudiante $0 Transportado por: Desde Fecha de salida: Hora de salida: (Localidad)

A Fecha de retorno: Hora de retorno: (Localidad)

Favor de estar a tiempo al recoger su hijo/a de la escuela.

Instrucciones adicionales del represetnante:

Nombre del coordinador

Yo, el que firma abajo, autorizo al personal de Tomball I.S.D. a contactar a la persona listada en esta hoja en caso de enfermedad, accidente y/o conducta inapropiada de mi hijo/a. Si yo o la persona en esta hoja no pueden ser contactadas, el personal de TISD está autorizado a tomar cualquier acción considerada necesaria, por la salud y seguridad de mi hijo/a. Entiendo que esta forma no cambia mis derechos como padre/tutor de mi hijo/a. He firmado esta forma voluntariamente para facilitar el tratamiento de mi hijo/a. No responsabilizaré al Distrito de Tomball o sus empleados por costos de cuidados de emergencia y/o transporte de mi hijo/a a cualquier institución médica. _______________________________ ______________________________________________________ Fecha Firma del padre o guardián

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Student and Family Survey

Name of Student

Name of Family Member(s)

Family Preferences in the Community

Where does your family shop for groceries? (Please circle those you shop at most often)

Wal-Mart Food Town HEB Kroger

Randall’s Fiesta Other:

Where does your family shop for miscellaneous household products? (Please circle those you shop at

most often)

Wal-Mart Dollar Tree Walgreen’s CVS

Target Dollar General Other:

What types of fast food does your family eat most often? (Please circle all that apply)

McDonald’s Burger King Wendy’s Sonic

Popeye’s Church’s Jack-in-the-Box Taco Bell

Subway Chick-Fil-A Other:

Does your family eat at “sit down” restaurants? If so, which ones do you frequent?

How often?

Does your family eat at buffet restaurants? If so, which ones do you go to and how often?

Which social/dining skills do you feel your child needs to improve on? (Please check all that apply)

Using utensils Money skills Controlling voice tone

Using napkin on lap Ordering for themselves Controlling portions

Other: Circle the stores that your family frequents. (Please circle all that apply)

Hobby Lobby Michael’s Lowe’s Home Depot

Office Depot Office Max Petco Petsmart

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Other:

What types of things does your family do for fun/recreation in the community?

We go to the movies at .

We go bowling at .

We play video/arcade games at .

We go to Park.

We play sports:

We go to Mall.

We play miniature golf at .

Other:

What other services does your family use in the community on a regular basis and that you expect

your child to use in the future? (Please circle all that apply and provide the name of the business).

Post Office Movie Rental

Library Drugstore

Bank Other

Are there any places you no longer go, as a family, because it is too difficult or frustrating for you or

your child? If so, which community sites would this include?

Does your child have any food restrictions or allergies?

What is your child’s favorite place to go in the community?

What is your child’s favorite food/restaurant?

Are there any concerns (such as behavioral) directly related to going into the community the teacher should be aware of?

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Please complete this checklist

This skill is very frustrating for my child.

It is much easier now, and always will be easier, if I do this skills for my child.

If the school would work on this skill, I would

involve my child in the activity when in the

community.

Making choices of things to eat or purchase

Asking for help

Waiting in line

Staying with a group

Using a public restroom

Being responsible for money/belongings

Finding items on a list

Paying for own purchases

Making purchases within a budget

Ordering own food

Selecting food from a buffet line

Sitting in a movie theatre

Dressing appropriately for an outing

What is your child’s clothing size?

What is your child’s shoe size?

Name of person completing survey

Telephone number

Email address

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Encuesta de alumnos y familias

Nombre del alumno:

Nombre de los miembros de la familia:

Preferencias de la familia en la comunidad

¿Dónde compra su familia los comestibles? (Encierre en un círculo las tiendas en las que hace las compras más a menudo)

Wal-Mart Food Town HEB Kroger

Randall’s Fiesta Otras:

¿Dónde compra su familia artículos misceláneos para el hogar? (Encierre en un círculo las tiendas en las que hace las compras más a menudo)

Wal-Mart Dollar Tree Walgreen’s CVS

Target Dollar General Otras:

¿Qué tipo de comida rápida consume su familia más a menudo? (Encierre en un círculo todas las opciones que correspondan)

McDonald’s Burger King Wendy’s Sonic

Popeye’s Church’s Jack-in-the-Box Taco Bell

Subway Chick-Fil-A Otras:

¿Concurre su familia a restaurantes más tradicionales? De ser así, ¿a qué restaurantes concurren más a menudo? ¿Con qué frecuencia concurren a los mismos?

¿Concurre su familia a restaurantes estilo buffet? De ser así, ¿a qué restaurantes concurren más y con qué frecuencia?

¿Qué destrezas sociales y qué modales a la mesa piensa usted que debe mejorar su hijo? (Encierre en un círculo

todas las opciones que correspondan)

Usar cubiertos Destrezas para el uso del dinero Controlar el tono de la voz Usa la servilleta en la falda Ordenar por sí mismos Controlar las porciones

Otras:

Encierre en un círculo las tiendas a la que frecuenta su familia. (Todas las que correspondan)

Hobby Lobby Michael’s Lowe’s Home Depot

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Office Depot Office Max Petco Petsmart

Otras:

¿Qué tipo de cosas hace su familia para divertirse/entretenerse en la comunidad?

Vamos al cine a .

Vamos a jugar bolos a .

Jugamos vídeojuegos o juegos de arcadia en .

Vamos al parque .

Jugamos deportes .

Vamos al centro comercial .

Jugamos al golfito en .

Otras: .

¿Qué otros servicios de la comunidad usa su familia regularmente que usted espera que su hijo continúe usando en el futuro? (Encierre en un círculo todos los que correspondan y escriba el nombre del negocio)

Oficina Postal _______ Alquiler de películas

Biblioteca Farmacia _______

Banco _______ Otros: _______

¿Hay algún lugar al que usted ya no concurre, en familia, porque es muy difícil o frustrante para su hijo? De ser así, ¿qué lugares de la comunidad están incluidos en esta categoría?

¿Tiene su hijo alguna restricción o alergia a algún tipo de alimento?

¿Cuál es el lugar preferido de su hijo en la comunidad?

¿Cuál es la comida o el restaurante favorito de su hijo?

¿Existe alguna preocupación (tal como conductual) directamente relacionada con ir de paseo a la

comunidad, que el maestro de su hijo deba saber?

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Marque la afirmación correspondiente en la siguiente lista:

Esta destreza es muy frustrante para mi hijo.

Es más fácil ahora y será siempre más fácil si yo hago esto por mi hijo.

Si la escuela ayudara con esta destreza, yo dejaría que mi hijo participara en

la actividad.

Hacer elecciones de cosas para comer o para comprar

Pedir ayuda

Esperar en fila

Permanecer con el grupo

Usar un baño público

Ser responsable por el dinero o las pertenencias

Encontrar artículos en una lista

Pagar por sus compras

Hacer compras dentro de su presupuesto

Ordenar su comida

Escoger la comida en un buffet

Ir al cine

Vestirse de manera apropiada para una salida

¿Qué talla de ropa usa su hijo? _____

¿Qué talla de calzado usa su hijo?

Nombre de la persona que llenó la encuesta

Número de teléfono

Dirección de correo electrónico

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Individualized CBI Plan Campus

Please attach

1. Master list of all students enrolled in life skills classes (this could be the Class Count) and their enrolled grade/age.

2. List of all Teachers 3. List of all Paraeducators

This form is located in the “CBI” folder on the intetnet – please use it to type in your information.

Group A List of students that can handle trips to large, stimulating environments

(Copperfield Bowl, Willowbrook Mall,

Wal-Mart), multiple stops, trips that are 2 hours+ in length. These

students would receive instruction in community settings up 5 times each

grading period.

Group B List of students that can handle 1.5 to 2 hour trips with no more than a total of 2 locations – they do best in

environments with limited stimulation (Kroger, Target,

JC Penney, Taco Cabana). These students would receive instruction in

community settings 3 or 4 times each grading period.

Group C List of students who learn best in small, single-room environments

with controlled stimulation (TCBY,

Dollar Tree, Subway). These students would receive instruction in

community settings for approximately 1 hour, 2 times per

grading period.

Now that students are in groups to better meet their individual needs, how will be the staff be used to provide

adequate instructional support in community settings? How and when can groups be combined into the same CBI trip?