Tier II Student Record Review
Student:_______________________________________Teacher:_____________________Grade:___
School:_______________________ Reviewer:________________________ Review Date:__________
Reason for review:
□ SRSS (#/21)_____ □ ODRs (#) _____ □ Request (by whom) ____________
Tardy
Total tardy &
absent out of
total days
/
Absent
/
Attendance
K
1
2
3
4
5
6
7
8
Has student been retained? ____________________________ If so, what grade(s)? _______________
Support the student is receiving or has received (indicate service and year):
□ Special Education____________________________________________________________
□ 504_______________________________________________________________________
□ Mental health services________________________________________________________
□ ELL services_______________________________________________________________
□ After School Programs________________________________________________________
□ Other:_____________________________________________________________________
State
Assessment
Scores
Language Arts
Math
Discipline
Grade 2
K
1
Grade 3
2
Grade 4
3
4
Grade 5
5
6
Grade 6
7
ODRs
Suspensions
Health Concerns:
Medications:
Concerns
Social-Behavioral Concerns:
Notes:
Grade 7
8
Total
Academic Concerns:
Notes:
Emotional Concerns:
Notes:
Operationally define behavior
Where does it occur?
When does it occur?
How frequently does it occur?
Hypothesized function
□ Skill deficit □ Adult attention □ Peer attention
□ Seeks tangible □ Seeks control □ Seeks stimulation
□ Avoid adults □ Avoid peers □ Avoid task/activity
□ Avoid situations □ Other:__________________________
Targeted Intervention Function Quick Sort
CHECK IN/
CHECK OUT
Increases opportunities for
positive adult attention
Increases opportunities for
positive peer attention
Promotes a positive,
encouraging adult relationship
Teaches replacement
behaviors and/or skills
Teaches problem solving
Increases precorrection,
prompts and structure
Monitors risk factors
Provides access to choice of
alternatives/ activities
Facilitates self monitoring
Increases opportunity for
stronger incentives/ positive
reinforcement
SOCIAL/
ORGNIZATIONAL
SKILLS GROUP
MENTORING
BEHAVIOR
CONTRACT
ALTERNATE
LUNCH/ RECESS
OTHER