CMCSS RTI Record
Instructions
Purpose: To collect educational data about a student’s progress during intervention.
Form Use: This form is completed when a student enters into Tier II or III intervention.
Instructions:
Demographic Information
Student Name: name of student receiving intervention
School: attending school
Grade: current grade placement
Date: date form is being completed
Tier: circle tier of intervention recommended for student
Multiple Tiers: circle Y if student is receiving tiered intervention in multiple subject areas (e.g., reading
and math) and N if student is receiving intervention in only one area.
Classroom Teacher: teacher of record
Parent Contact Information: write in parent(s) name(s) and method of contact (e.g., phone number,
email address, etc.)
Summary of Evidence Considered
Current Grades: list current grades (numerical, if possible) for each subject area. For subjects not listed,
include in “other” space
Reading/Math Percentile Scores: write in national percentile scores of universal screener for fall (F),
winter (W) and spring (S) administrations. When initially completing form, only one set of scores
may be available; remember to come back and fill in additional scores as they become available.
Health Concerns: list any health concerns. If health concerns are listed, a 504 referral should occur.
504 Referral: check ‘Yes’ if student has a 504 referral and ‘No’ if they do not.
Failed Grades/Subjects and Other Evidence: list grades retained, failed subjects or other evidence the
team should consider as part of intervention decision(s).
Skill Deficit Area: circle the area where deficit is first evidenced. For example, if a student has a decoding
deficit, which affects fluency and comprehension, only decoding should be circled, as it is the
first area of intervention. As deficits are remediated, a new skill deficit may be chosen.
For students with deficits in multiple subjects (e.g., reading and math), each area should be
addressed on a separate form.
Data-Based Intervention Decision Summary
Name of Intervention: write in name of intervention (e.g., Academy of Reading – Phonics, FCRR -- onset
and rime, Intervention Central – word supply)
Skill Addressed: specify the skill area of focus for the intervention. For example, if comprehension is
marked as the skill deficit, you would specify here if the intervention focuses on main
idea/summarizing, monitoring for meaning, monitoring for understanding, narrative text
structure, expository text structure, sentence meaning, story structure, text analysis, etc.)
Intervention Teacher: name of person providing intervention
Time per Session: total time per session student participates in intervention
Pupil / Teacher Ratio: ration of intervention students to person providing intervention
Progress Monitoring Frequency: circle ‘EOW’ for every other week, or ‘weekly’ for each week
Date of Review: write in the date progress monitoring data was reviewed by RTI team
Tier Placement: circle the number corresponding to the tier level of intervention
Change Summary: describe any changes made to the intervention or PM schedule (e.g., time of day,
provider, intervention, duration, etc.).
Parent Contact Record
Date of Contact: document contacts made with parents, including initial contact explaining participation
in intervention, when data letters/graphs are sent every 4-4.5 weeks, etc.
Contact Summary: describe outcome/purpose of contact (e.g., entering/discontinuing intervention,
communicate PM data, in event of referral for SPED evaluation, and dates/duration of universal
screening, etc.)
Person Responsible: list person making parent contact
CMCSS RTI Fidelity Record
Instructions
Purpose: To monitor data collected during a student’s participation in tiered intervention.
Form Use: This form is completed during the time a student participates in Tier II or III intervention.
Instructions:
Student Name: name of student receiving intervention
School: attending school
Year: academic year
Date: in the box beside the numbered weeks, write in the dates corresponding to that time period
Time of Day: list the time period when intervention is delivered (e.g., 9-9:30; 10-10:45)
M/T/W/T/F: use the key above the weekly heading to indicate student/teacher absence, holiday or
other reason for missed intervention (tardy)
% Total: calculate the percentage of time the student received intervention, as prescribed in plan
Direct Observation: document the date and score from the Student Direct Observation Rubric
Data Review Additional Notes: document the date and PM decision from the RTI Record
Lesson Plans Checked: write in dates lesson plans are checked. If this is done routinely on a scheduled
basis, ‘weekly on Tuesdays’ is an example of how to document the date, rather than list the date
of each Tuesday
Schedule Checked: document date when teacher-submitted schedule was checked. This may occur
1x/semester in middle/high school settings, where schedules are maintained due to creditearning courses
Fidelity Monitor Signature: signature of person monitoring fidelity of intervention delivery