STUDENT NAMECLICK HERE
TO ENTER TEXT.
HOMEROOM/GRADECLICK HERE TO ENTER TEXT.
Date of Birth: Click here to enter
a date.
WAYNE COUNTY KSI/RTI CHECKLIST
TIER I / CORE
INSTRUCTION –
TEACHER COMPLETES
AND RETURNS TO
PRINCIPAL
☐Universal Screener
Evidence as required by
school and districtName/Results_____________
______________________
____________________
Choose an item.
____________________
________________

o Meet with Parent
o Additional
diagnostic
assessment
☐Highly Effective
Reading/Writing/Math/
Behavioral Instruction of
required curriculum (80 % of
all students are mastering
content)
☐Effective Classroom
discussions, questioning and
learning tasks
evidence___________
__________________
___
an item.
____________________
________________

Documentation of
Effective Learning
Strategies

Click here to enter a
date.(START) Repeat
Click here to enter a
date.(START)Additional
use of
manipulatives/engageme
nt (END)Click here to enter a date.
Evidence Choose an
o Progress
Monitoring of
all students
o Data Collection Plan
☐Clearly defined learning and
behavioral targets in studentfriendly language
☐Differentiated Instruction
Click here to enter a
date.(START)Frequent
Feedback (END).Click here to
enter a date. Evidence Choose
Click here
to enter a date.
☐Focused, descriptive,
qualitative, and frequent
feedback to students
☐Critical and creative thinking
prompts or questions
independent)(END)Click here
to enter a date. Evidence
item.
____________________
________________

Click here to enter a
date. Other
(END)Click here to
enter a
date._____________
Evidence Choose an
item.
☐Student engagement in selfassessment, self-reflection
and peer analysis based on
learning and/or behavioral
targets
explicit
teaching.(END)Click here to enter
a date.Evidence Choose an
☐Student work/behavior
models that meet the
learning/behavior target
____________________
________________
☐If progress is not shown
Click here to enter a
date.(START)Direct
complete and turn all
information into principal.
item.
Intensive
instruction.(END)Click here to
enter a date. Evidence Choose
☐Vision
an item.
☐Hearing
☐Motor
☐Communication

☐Attendance (Days Missed
____ out of ___ #
Tardy(s)____
Meet with Parent/Student
Intervention TeamClick here
to enter a date.
____________________
________________
☐Free/Reduced Lunch
Click here to enter a
date.(START)Structured
☐Has Been Retained
overviews. (END) Click here to
enter a date. Evidence Choose

____________________
________________
☐Migrant/Frequent Moves
☐Problems at Home
☐Family Resource Use
an item.
☐Limited English
____________________
________________
☐Involved in Court System
Click here to enter a
date.(START)Drill and
practice (guided and/or
R
i
s
k
☐Does not live with parents
☐Involved w/ Mental Health Agency
☐Speech Language Services
☐Special Education
F
a
c
t
o
r
s
STUDENT NAMECLICK HERE
TO ENTER TEXT.
HOMEROOM/GRADECLICK HERE TO ENTER TEXT.
WAYNE COUNTY KSI/RTI CHECKLIST
TIER II/ TARGETE D
LEVEL- COM P LET ED
D UR I N G COM M I T T EE
M EET I NG
☐Based on the evidence
from the screener,
homeroom teacher,
diagnostic assessments…
the Intervention Team
(including Parent) CREATE
TARGET MEASURABLE
GOAL/S. Choose an
item.___________________
______________________
______________________
______________________
☐The Intervention Team
completes Student
Proficiency Plan by
determining the
o Method of
Delivery
o Frequency
o Intensity
o Duration
o Schedule
o Resources
needed
o Progress
monitoring
tools/frequency
o Next review date
o Tier I continues
in regular
classroom
☐IMPLEMENTATION OF
GOAL/S BY REGULAR
CLASSROOM AND RTI TIER
TEACHER/S
o SCAFFOLD OF
INSTRUCTION
o PROGRESS
MONITORING
o Increase
Frequency?
o Increase
intensity?
o Enter Tier III
Level

☐If goal is being met after
4 data points (displayed
on graph) by the agreed
upon diagnostic assessment
instrument…..

o Raise goal –
continue or
complete
intervention
o Achieved Goal –
move back to
Tier I
☐COMPLETE
PAPERWORK
WCSI – Student
Proficiency Plan
Document)
☐If goal is not met or
behind/delayed after 4 data
points (displayed on graph)
by the agreed upon
diagnostic assessment
instrument…..
o Meet with
Parent/Intervent
ion TeamClick here to enter
a date.
o Change
intervention?
Increase
Frequenc
y? (Tier
II or III)
Increase
intensity?
(Tier II
or III)
☐COMPLETE
PAPERWORK
(WCSI – Student
Proficiency Plan
Document)
STUDENT NAMECLICK HERE
TO ENTER TEXT.
HOMEROOM/GRADECLICK HERE TO ENTER TEXT.
WAYNE COUNTY KSI/RTI CHECKLIST
o Next review date
TIER III/ INTENSE
LEVEL COM PL ET ED
D UR I N G COM M I T T EE
M EET I NG
☐Based on the evidence
from the progress
monitoring, homeroom
teacher, RTI teacher… the
Intervention Team
(including Parent)
4/20/2015INCREASES
INTENSITY AND
FREQUENCY OF SERVICES
TO MEET THE TARGET
MEASURABLE GOAL/S.
Choose an
item.___________________
______________________
______________________
______________________
☐The Intervention Team
UPDATES Student
Proficiency Plan by
determining the
o Method of
Delivery
o Frequency
o Intensity
o Duration
o Schedule
o Resources
needed
o Progress
monitoring
tools/frequency
Tier I continues
in regular
classroom
o Tier II Continues
☐IMPLEMENTATION OF
GOAL BY REGULAR
CLASSROOM AND RTI TIER
TEACHER/S
o SCAFFOLD OF
INSTRUCTION
o PROGRESS
MONITORING
☐If goal is being met after
4 data points (displayed on
graph) by the agreed upon
diagnostic assessment
instrument…..
o Raise goal –
continue or
complete
intervention
o Achieved Goal –
move back to
Tier I
☐COMPLETE
PAPERWORK
(WCSI – Student
Proficiency Plan
Document)
☐If goal is not met or
behind/delayed after 4 data
points (displayed on graph)
by the agreed upon
diagnostic assessment
instrument…..
o Meet with
Parent/Intervent
ion TeamClick here to enter
a date.
o Change
intervention?
o Increase
Frequency?
o Increase
intensity?
o Referral for
special
education/gifted
education formal
evaluation
☐COMPLETE
PAPERWORK
(WCSI – Student
Proficiency Plan
Document)