Response to Intervention For

RESPONSE TO INTERVENTION FOR

LEARNING DISABILITY OR BEHAVIOR

Name: / School:
DOB: / Grade:

RESPONSE TO INTERVENTION (RtI) MODEL:Response to Intervention is high-quality instruction or tiered intervention strategies matched to individual needs of the child that have been demonstrated through scientific research and practice that result in high learning rates for most children.

Section 1

Yes No

The student has participated in a RtI process. If yes, instructional strategies and lack of achievement are

identified in Section 2.

Yes No

The parent/adult student was notified about the state’s policies regarding the amount and nature of the

performance data of the child that would be collected and the general education services that would be

provided.

Yes No

The parent/adult student was notified about strategies for increasing the child’s rate of learning.

Yes No

The parent/adult student was notified about his/her right to request an evaluation.

Section 2

1stTargeted area of achievement
(Address lack of adequate achievement) / Scientific Research-Based Intervention
(Examples: Istation, Voyager, VMath, behavior strategies) / Duration Received
(Date started in Tier 3 to present date) / Frequency & Duration
of Intervention
(Example: 2 X wk for 30 min)
Phonemic AwarenessGraphophonemic KnowledgeVocabularyReading FluencyReading ComprehensionNumber & OperationsAlgebraGeometryMeasurementData Analysis & ProbabilityMath ProcessBehavior
Repeated curriculum-based assessments
(Examples: nonsense word fluency, phonemic segmentation fluency, number sequence, place value, addition/subtraction, behavior chart) / Progress Monitoring (Dates of DataPoints) / Progress Monitoring Scores
Compared to Goal
(Example: 190/240)
1.
2.
3.
2nd Targeted area of achievement
(Address lack of adequate achievement) / Scientific Research-Based Intervention
(Examples: Istation, Voyager, VMath, behavior stategies) / Duration Received
(Date started in Tier 3 to present date) / Frequency & Duration
of Intervention
(Example: 2 X wk for 30 min)
Phonemic AwarenessGraphophonemic KnowledgeVocabularyReading FluencyReading ComprehensionBehaviorNumber & OperationsAlgebraGeometryMeasurementData Analysis & ProbabilityMath Process
Repeated curriculum-based assessments
(Examples: nonsense word fluency, phonemic segmentation fluency, number sequence, place value, addition/subtraction, behavior chart) / Progress Monitoring (Dates of Data Points) / Progress Monitoring Scores
Compared to Goal
(Example: 190/240)
1.
2.
3.
3rdTargeted area of achievement
(Address lack of adequate achievement) / Scientific Research-Based Intervention
(Examples: Istation, Voyager, VMath, behavior strategies) / Duration Received
(Date started in Tier 3 to present date) / Frequency & Duration
of Intervention
(Example: 2 X wk for 30 min)
Phonemic AwarenessGraphophonemic KnowledgeVocabularyReading FluencyReading ComprehensionNumber & OperationsAlgebraGeometryMeasurementData Analysis & ProbabilityMath ProcessBehavior
Names of Repeated Curriculum-Based Assessments
(Examples: nonsense word fluency, phonemic segmentation fluency, number sequence, place value, addition/subtraction, behavior chart) / Progress Monitoring (Dates of Data Points) / Progress Monitoring Scores
Compared to Goal
(Example: 190/240)
1.
2.
3.
4th Targeted area of achievement
(Address lack of adequate achievement) / Scientific Research-Based Intervention
(Examples: Istation, Voyager, VMath, behavior strategies) / Duration Received
(Date started in Tier 3 to present date) / Frequency & Duration
of Intervention
(Example: 2 X wk for 30 min)
Phonemic AwarenessGraphophonemic KnowledgeVocabularyReading FluencyReading ComprehensionNumber & OperationsAlgebraGeometryMeasurementData Analysis & ProbabilityMath ProcessBehavior
Repeated Curriculum-Based Assessments
(Examples: nonsense word fluency, phonemic segmentation fluency, number sequence, place value, addition/subtraction, behavior chart) / Progress Monitoring (Dates of Data Points) / Progress Monitoring Scores
Compared to Goal
(Example: 190/240)
1.
2.
3.

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SignatureDate