Response to Intervention

Referral Forms

Student ID ______Birth date: ___/___/___
Student Name: ______
School: ______Teacher:______Grade: ______
Parent(s): ______Phone: ______
Address: ______
Reason for Referral: □ Academic □ Behavior
ATTENDANCE
Days absent last year ______
Days absent this year ______
Other schools attended: ______
______
______
Retentions: Yr(s) ___Gr(s)___
Previous enrollment in Special Education/Section 504 ______
Is the student identified as:
ELL (English Language Learner)
(circle one) Yes No / HEALTH
Hearing:
Date ______
Results ______
Recheck needed _____
Vision:
Date ______
Results ______
Recheck needed _____
Other: ______
______/ DISCIPLINE
Number of discipline reports ______
Number of suspensions:
In-school ______
Out-of-school ______
Other ______
______
______
Screening / Fall / Winter / Spring
MAP
DIBELS
CSD Benchmark
Other

Note: Use the data collected from the diagnostic inventories to determine areas of concern in order to locate the first skill set where intervention

should begin. Refer the RtI Diagnostic Toolkit for specific grade level and skill information. Use the following page to record the intervention

plan.

All student specific data and graphs must be attached!

Student Name ______School ______Grade ______Teacher ______Year______

Christina School District Student Literacy Intervention Plan: Response to Intervention (K-5)

Tier I @ Risk
40th%ile - benchmark
Core Classroom Instruction
Houghton Mifflin Reading / Tier II: (Cycle I)
Date:______
25-40th%ile
90 minutes per week/targeted intervention/in addition to core instruction / After first cycle of Tier II Intervention (six weeks) / Tier II: (Cycle II)
Date:______
(Based on Student Need) / Tier III: (Cycle I)
Date:______
below 25th%ile
150 minutes per week/targeted intervention/in addition to core instruction
All students will receive 90 minutes of reading instruction daily with fidelity to the curriculum. The 90 minutes of instruction will also incorporate differentiated, flexible small groups to address specific student strengths and/or weaknesses.
Progress Monitoring:
Tool / Date / Results
/ Focus of Intervention:
______
______
______
Interventions:
□  Fundations
□  Soar to Success
□  Road to the Code
□  ERI
□  Earobics
□  Reading Mastery
□  Corrective Reading
□  QuickReads
□  Early Success
□  Other ______/ Next Step:
Choose one of the following –
□  Continue Tier II intervention with the following modification:
______
______
______
______
______
□  Address another need.
PLC Review Date: ______ / Focus of Intervention:
______
______
______
Interventions:
□  Fundations
□  Soar to Success
□  Road to the Code
□  ERI
□  Earobics
□  Reading Mastery
□  Corrective Reading
□  QuickReads
□  Early Success
□  Other ______/ Focus of Intervention:
______
______
______
Interventions:
□  Fundations
□  Soar to Success
□  Road to the Code
□  ERI
□  Earobics
□  Reading Mastery
□  Corrective Reading
□  QuickReads
□  Early Success
□  Other ______
Screening Results: DIBELS
Month / Day / Results
Aug/Sept
Jan
May
Diagnostic Results:
(to determine targeted instruction for Tier II)
Tool / Date / Results*
*use back of page if needed / Timeline:
(6 weeks: 90 min. per week)
______to ______
Date Date
Progress Monitoring:
Tool / Date / Results
Proceed to next step at top of page… / PLC Notes/Comments:
Follow-up:
Timeline: / Timeline:
(6 weeks: 90 min. per week)
______to ______
Date Date
Progress Monitoring:
Tool / Date / Results
PLC Review Date: ______
Decision:
□  Dismiss from Tier II
□  Continue Tier II interventions
□  Move to Tier III AND refer to RtI Core team / Timeline:
(6 weeks: 150 min. per week)
______to ______
Date Date
Progress Monitoring:
Tool / Date / Results
RtI Team Review Date: ______
Decision:
□ Continue Tier III with modification: ______
______
AND review with RtI Core Team

Insert this page for additional intervention cycles and comments.

Tier III: (Cycle II)
Date:______/ Tier ___: (Cycle __)
Date:______/ Tier ___: (Cycle __)
Date:______/ Comments:
Focus of Intervention:
______
______
______
Interventions:
□  Fundations
□  Soar to Success
□  Road to the Code
□  ERI
□  Earobics
□  Reading Mastery
□  Corrective Reading
□  QuickReads
□  Early Success
□  Other ______/ Focus of Intervention:
______
______
______
Interventions:
□  Fundations
□  Soar to Success
□  Road to the Code
□  ERI
□  Earobics
□  Reading Mastery
□  Corrective Reading
□  QuickReads
□  Early Success
□  Other ______/ Focus of Intervention:
______
______
______
Interventions:
□  Fundations
□  Soar to Success
□  Road to the Code
□  ERI
□  Earobics
□  Reading Mastery
□  Corrective Reading
□  QuickReads
□  Early Success
□  Other ______
Timeline:
(6 weeks: 150 min. per week)
______to ______
Date Date
Progress Monitoring:
Tool / Date / Results
RtI Team Review Date: ______
Decision:
□  Exit to Tier ___
□  Continue Tier ___
□  Refer for further assessment / Timeline:
(6 weeks: ___ min. per week)
______to ______
Date Date
Progress Monitoring:
Tool / Date / Results
RtI Team Review Date: ______
Decision:
□  Exit to Tier ___
□  Continue Tier ___
□  Refer for further assessment / Timeline:
(6 weeks: ___ min. per week)
______to ______
Date Date
Progress Monitoring:
Tool / Date / Results
RtI Team Review Date: ______
Decision:
□  Exit to Tier ___
□  Continue Tier ___
□  Refer for further assessment

CSD C & I (1/09)