Response to Intervention (RTI) Plan

Follow-up

Currently @ Tier 2or Currently @ Tier 3 orReceiving Outside Support

Student Name: DOB: Age: Grade: School:

Bibb ID: Date of Meeting:

Were the strategies and interventions carried out with fidelity? Yes No

If no, please explain:

Have the short-term goals been met? Yes No

If no, please explain:

Recommendations

RtI Follow-Up Form

Revised 11-2-13

If Currently in Tier 2:If Currently in Tier 3:

Continue/modify current interventions Continue/modify current interventions

Return to Tier 1(support as needed) Return to Tier 2 (explain below)

Refer to Tier 3/SST (describe below) Refer for an evaluation for consideration of services

Other (describe below)fromthe Program for Exceptional Children (i.e.psychological

evaluation, speech-language evaluation, etc. - explain below); interventions continue while testing is being completed

Comments/Recommendations: _______

______

*attach appropriate documentation to show intervention outcomes (data including intervention log, line graphs, charts, etc.)

I agree for the Bibb County Schools to conduct a hearing and vision screening; diagnostic assessment on my child, which may be completed by a diagnostician and/or school psychologist.

I do not agree for the Bibb County Schools to conduct a hearing and vision screening; diagnostic assessment on my child.

RtI Follow-Up Form

Revised 11-2-13

RtI Follow-Up Form

Revised 11-2-13

Team Members:

RtI Follow-Up Form

Revised 11-2-13

Classroom Teacher

Specialized Support Staff/Title

Name/Title

Parent

Administration (optional)

Name/Title

RtI Follow-Up Form

Revised 11-2-13

If parent was unable to attend, document the date they were contacted with the results: , (date), by

whom and method of contact (check): phone letter in person Other

If checked, please see attached comments.

RtI Follow-Up Form

Revised 11-2-13

Student Name: DOB: Age: Grade: School:

Short-Term Measurable Goal #1:
  • Condition or Stimuli
  • Observable Student Behavior
/ Baseline Data:
(Date and Data) / Criteria of Mastery:
*At a Specific Level
*For a Specific Amount of Time / Frequency of Measurement:
(Min/Day; Days/Wk after minimum 4hrs instruction) / Evaluation Methods:
(Progress Monitoring Tool) / Date Mastered or Results:
(Since last meeting)
Research-Based Strategies/Interventions to be Implemented: / Start and Ending Dates: / Title of Person Responsible: / Location of Strategies /Interventions (small group, pull-out, etc.): / Frequency (min/hrs/wk):
Short-Term Measurable Goal #2:
  • Condition or Stimuli
  • Observable Student Behavior
/ Baseline Data:
(Date and Data) / Criteria of Mastery:
*At a Specific Level
*For a Specific Amount of Time / Frequency of Measurement:
(Min/Day; Days/Wk after minimum 4hrs instruction) / Evaluation Methods:
(Progress Monitoring Tool) / Date Mastered or Results:
(Since last meeting)
Research-Based Strategies/Interventions to be Implemented: / Start and Ending Dates: / Title of Person Responsible: / Location of Strategies /Interventions (small group, pull-out, etc.): / Frequency (min/hrs/wk):
Short-Term Measurable Goal #3:
  • Condition or Stimuli
  • Observable Student Behavior
/ Baseline Data:
(Date and Data) / Criteria of Mastery:
*At a Specific Level
*For a Specific Amount of Time / Frequency of Measurement:
(Min/Day; Days/Wk after minimum 4hrs instruction) / Evaluation Methods:
(Progress Monitoring Tool) / Date Mastered or Results:
(Since last meeting)
Research-Based Strategies/Interventions to be Implemented: / Start and Ending Dates: / Title of Person Responsible: / Location of Strategies /Interventions (small group, pull-out, etc.): / Frequency (min/hrs/wk):

RtI Follow-Up Form

Revised 11-2-13

*Refer to samples provided

RtI Follow-Up Form

Revised 11-2-13