Grayson County Schools
Tier 2 Math
Referral Recordof Intervention
Student Name ______SchoolCaneyville Clarkson Lawler WilkeyGCMS Grade _____
Teacher ______First RTI Consideration: Yes No Date ______
Demographic and Attendance Data Attach the following Infinite Campus Reports:
Student Profile Report□ Student Attendance/Enrollment Report
Is attendance a problem for this student? Yes No
(Did the student miss 10 or more days during the previous school year? Have they missed more than 6% of the current
year?)
Has the student been retained? □Yes □ No
I have observed problems that interfere with his/her education progress in the following area(s): Check all that apply.
_____ Academic performance, low or failing grades _____ Medical
_____ Behavior and/or discipline_____ Other, specify ______
Summary of Most Recent Math Grades
Provide a copy of the student’s most recent report card.
Assessment Data indicate the student has potential to struggle/ at-risk in Math
Please check (all that apply/minimum of 3)andattach data that has been analyzed to determine area(s) of concern(on grade level data that will demonstrate comparison to peers):
□Universal Screener (STAR)*Required
□Diagnostic Assessments
□Fluency Checks (on grade-level checks and instructional level checks)
□School Level Standards-based Common Assessments- (Results should show how the student performed in relation to peers)
□District Level Standards-based Common Assessments- (Results should show how the student performed in relation to peers)
□Other ______
□Other ______
Briefly describe the interventions you have tried during Core Instruction and the results attained.
Intervention Plan
(To be completed by RtI Team prior toimplementing Tier 2 Instruction)
Goal Setting: Circle primary area of concern below.Number Sense
□Subitizing _____w/in 5 _____w/in 10 _____w/in 20
□Number Magnitude (more/less-concrete/pictoral)
□Counting _____Numeral Recognition _____Number Sequence
□One-to-One Correspondence
□Cardinality
Number & Operations in Base Ten
□Composing
□Decomposing
□Comparing (<,>) _____whole numbers _____fractions/decimals
Operations and Algebraic Thinking
□Basic Fact Fluency _____addition /subtraction _____multiplication /division
□Addition/Subtraction
- Strategies _____whole numbers _____fractions/decimals
- Properties of operations
- Algorithm _____within 10 _____within 20 _____ within 1000
- Problem Solving
- Strategies _____whole numbers _____fractions/decimals
- Properties of operations
- Algorithm _____two-digit by one _____three-digit by one _____two-digit by two _____other
- Problem Solving
- Factors/Multiples
□Part-whole relationship
□Equivalence
□Ordering
□Compare
□Add/Subtract _____like denominators _____unlike denominators _____mixed numbers
□Multiply/Divide
Min./Day
20 25 30 / Days/Week
2 3 4 / Est. # Weeks
8 9 10 11 12 / # Sessions
Instructional Model: Small Group One-on-One
Person Responsible for Implementing the Intervention:
Intervention Program or Strategy to be Used:
How will progress be monitored (Assessment Tool)?
How often will progress be monitored and data points graphed?
Daily Weekly Biweekly (every 2 wks) Every _____ Sessions
Has the student made sufficient progress to meet age or state-approved grade-level standards in the areas identified in response to carefully planned and explicitly delivered intervention instruction? Yes No
Tier 2 Interventions Lesson Planning Tool: (Line Graph Documenting Progress Monitoring Data must be Attached)
Student Name: ______Homeroom Teacher: ______
Interventionist: ______Tier 2 Start Date: ______
Skill to be addressed:
Goal:
Research-based Strategy/Activity / Date (begin/end)Next Steps:
Intervention StatusParent Notified
Problem resolved; return to CoreLetter
Problem not resolved; redesign or modify Tier 2 interventionPhone
Problem not resolved; add Tier 3.Date of Contact ______
______
Principal/DesigneeDate of Review
Revised May 2015