PBIS Implementation Survey

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* 1. District Name

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* 2. Your Name

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* 3. Your email address

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* 4. Your Role

District PBIS Coach

School PBIS Coach

Principal

School Counselor

Director of Pupil Personnel

Director of Special Education

Assistant Superintendent

Other (please specify)

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* 5. Please list any schools currently implementing PBIS in the district you are responding about. (If none, enter "none".)

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* 6. Are you or other schools in your district interested in implementing PBIS?

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* 7. School or District Contact's Phone Number (e.g. PBIS Coach or PBIS Coordinator, if applicable)

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* 8. Educational Cooperative Region

Central Kentucky Educational Cooperative

Greater Louisville Educational Cooperative

Green River Regional Educational Cooperative

Kentucky Educational Development Cooperative

Kentucky Valley Educational Cooperative

Northern Kentucky Cooperative for Educational Services

Ohio Valley Educational Cooperative

Southeast/South Central Education Cooperative

West Kentucky Educational Cooperative

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* 9. If using PBIS please choose how many years of implementation at each Tiered Level.

	Less than a year	1-2 years	3-5 years	6+ years	Not implementing
Tier I	Tier I Less than a year	Tier I 1-2 years	Tier I 3-5 years	Tier I 6+ years	Tier I Not implementing
Tier II	Tier II Less than a year	Tier II 1-2 years	Tier II 3-5 years	Tier II 6+ years	Tier II Not implementing
Tier III	Tier III Less than a year	Tier III 1-2 years	Tier III 3-5 years	Tier III 6+ years	Tier III Not implementing

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* 10. Which PBIS tool(s) do you currently use?

ASA (ABRI School Assessment)

Early Childhood Benchmarks of Quality (ECBoQ)

School Climate Survey

School Safety Survey (SSS)

Self-Assessment Survey (SAS)

Team Implementation Checklist (TIC)

Tiered Fidelity Inventory (TFI)

TFI Companion Guide

Other (please specify)

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* 11. If trained in PBIS, where were you previously trained?

ABRI

KyCID

Co-op

District Level Training

No prior training

Other (please specify)

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* 12. Are you still receiving supports from one of the above mentioned groups in PBIS?

Yes

Does not apply

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* 13. Is your school receiving school-based mental health services provided by community mental health agencies and/or other mental health practitioners?

Yes – Both private practitioners and community mental health center practitioners

Yes – From one or more Community Mental Health Centers (Lifeskills, Bluegrass, Adanta, Centerstone, Mountain Comp Care etc.)

Yes – Private practitioners

Other (please specify)

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* 14. Has your school or district received training on the integration of mental health services into the ISF framework?

Yes

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* 15. What type of supports would you be interested in?

Academics

Mental Health & the Interconnected Systems Framework

Special Education

Behavior

Data tools & usage

PBIS

Integrating Cultural Competency into PBIS

School Climate and Safety

Trauma Informed Practices

Other (please specify)