School Name:

Annual Student Outcome Goal:

ASCA Student Standards (Limit of two standards)

1.

2.

Mindsets & Behaviors Pre-/Post-Assessment Statements

1.

2.

3.

4.

Interventions That Support Achieving the Annual Student Outcome Goal

Describe Direct Student Services (minimum of two)

Describe Indirect Student Services (minimum of two)

1.

2.

3.

1.

2.

3.

Systemic Focus

Identify school or system policies, procedures or practices that create or maintain inequities relevant to this goal.

List 1–2 strategies that could influence systemic change related to this goal.

Baseline Data

Results Data

Participation Data Plan

Participation Results Data

Anticipated

Actual

Mindsets & Behaviors Pre-Assessment Results

Mindsets & Behaviors Post-Assessment Results

Pre-Assessment Data

(Calculate the average student response for each item)

1.

2.

3.

4.

Post-Assessment Data

(Calculate the average student response for each item)

1.

2.

3.

4.

Outcome Data Plan

Outcome Data Results

Baseline Data:

Final Data:

Percent Change:

Reflection

· How did the interventions facilitate the attainment of identified ASCA Student Standards?

· How could the interventions be improved (e.g., consider timing, number and type of services, student access and identified barriers)?