Tier I: All Settings, All Students, Preventative, Proactive
 Core  Core-Supplemental  ESE  ESOL  504 Plan
 Tier ___, Interventionist:
 Tier ___, Intervention:
 Tier ___, Interventionist:
 Tier ___, Intervention:
SAINT LUCIE PUBLIC SCHOOLS
VILLAGE GREEN ENVIRONMENTAL STUDIES SCHOOL
MTSS/RtI-A  Academic Concern Report
Dear Parent or Guardian, We respectfully request your support to resolve the academic concerns mentioned below. This form is used to document academic concerns.
Student:
Teacher:
Grade:
Benchmarks
Date
Phonics
Assessment
Type
Score
Word Study/Vocabulary
Assessment
Score
Type
Date
PERFORMANCE DATA PROFILE
COMMON ASSESSMENTS
Fluency
Reading Comp
Assessment
Assessment
Date
Score
Date
Score
Type
Type
Date
Written Expression
Assessment
Score
Type
Date
Math
Assessment
Type
Score
easyCBM
 LN_______
 LS_______
 PS_______
 WRF_____
 PRF______
 MCRC____
 Vocab____
 Math_____
Comp 1
 ELA______
 Math_____
 Science___
Comp 2
 ELA______
 Math_____
 Science____
Lexile: ______
_____ _____
_____ _____
Phonics
Letter Names Upper Case
Letter Names Lower Case
Letter Sounds Upper Case
Letter Sounds Upper Case
CVC Words
Digraphs
Trigraphs
Consonant Blends
Long Vowels
r- controlled vowels
l- controlled vowels
Diphthongs
Two Syllable
Word Study/Vocabulary
Two Syllable
Multisyllabic
High-Frequency Words
Word Parts
Prefixes
Suffixes
Affixes
Words in Context
Academic Vocab.
Domain Specific Vocab.
Figurative Language
Denotative Meanings
Connotative Meanings
Classroom Interventions & Differentiated Instruction
Fluency
Reading Comp
Oral/Word Reading
Oral/Sentence Reading
Oral/Paragraph Reading
Oral/Passage Reading
Phrasing
Expression
Attending to Text
Dialogue
Paired/Partner Reading
Choral Reading
Repeated Reading
Pencil Tap/Stop-Go
Reader’s Theatre
PARENT CONTACT PRIOR TO CONFERENCE:  Planner  Phone  Other:
Date:
Written Expression
Retelling
Main Ideas
Key Details
Story Elements
Compare/Contrast
Cause/Effect
Sequencing
Author’s Perspective
Drawing
Conclusions/Inference
Problem/Solution
Textual Elements
Reciprocal Teaching
Time:
Cover-Copy Compare
Increased Opportunities for
Responding
Thinking Maps
Organization and Structure
Planning
Proofreading and Editing
RAFT
Quick Writes
Sentence Diagraming
Sentence Combining
Writing Summaries
Writing Frames
Math
Go Math! Core
Calendar math routine
Whole Number Fluency
Whole Numbers Properties
4th – 5th Long Division
4th – 5th Rational Numbers
Meanings fractions, ratios,
decimals, percent
Visual representation of
fractions, ratios, decimals,
percent on number lines
Solving word problems with
fractions, ratios, decimals,
percent on number lines
Notes:
Parent Notification  Conference Required
Failure to attend, may result in further academic difficulty; and consequently, there is the danger of failure. It is necessary that the cause(s) of this deficiency be understood and the recommendation(s) be followed.
 Parent Teacher Conference (following 1st Notice)
 Problem Solving Team (following Subsequent Notices)
Date of Conference: ____________
Possible Causes for Deficiency
 Lack of Motivation  Attendance/Tardy  Poor Test Scores  Missing/Incomplete Homework  Lack of Attention or Participation  Other:
Recommendations
 Pay Attention in Class  Ask & Answer Questions  Practice Skills at Home  Engage in Classwork  Arrive to School on Time
 Submit Assignments
 Make Adequate Progress in Reading Counts
 Make Adequate Progress with IXL Skills
 Other:
Type of Conference:
Parent Name: ________________________________ Parent Signature:______________________________________ Date:________________________
White: Teacher
Canary: Parent
Pink: Principal
Goldenrod: Guidance Counselor
VGE0019