MTSS Self-Assessment (Program/Building/District)
Program/Building/ District:
Building:
Date of Self-Assessment Completion:
_
The purpose of this self-assessment is to gather information regarding the extent to
which various components of MTSS/Response to Intervention are in place in your
program/building/district.
Your team will work together to complete this assessment. Each group member is
receiving a copy of the assessment; however, only one form should be recorded per
team.
Your team should discuss and reach agreement about the status for each item (Not
Started, In Progress, Achieved, and Maintaining). In addition, the leadership team
should provide comments/evidence for each item. We ask that all members of the
team participate in this process.
Please submit your team’s self-assessment by:
Questions regarding the assessment may be directed to
Rebecca Buxton buxton@sresd.org
Self-Assessment
Program/Building/District Based Leadership Team Members (Name & Position)
Person(s) Completing Report (Name & Position)
* Adapted from the Florida Problem Solving/Response to Intervention Project and the IL-ASPIRE SAPSI v. 1.6
Center for School Evaluation, Intervention and Training (CSEIT)
Loyola University Chicago, Influences by MiBLSi, IISD,
HISD
2
MTSS Self-Assessment
Directions:
In responding to each item below, please use the following response scale:
Not Started (N) — (The activity occurs less than 24% of the time)
In Progress (I) — (The activity occurs approximately 25% to 74% of the time)
Achieved (A) — (The activity occurs approximately 75% to 100% of the time)
Maintaining (M) — (The activity was rated as achieved last time and continues to occur approximately
75% to 100% of the time)
For each item below, please write the letter of the option (N, I, A, M) that best represents your Program Based Leadership
Team’s response in the column labeled “Status”. In the column labeled “Comments/Evidence”, please write any comments,
explanations and/or evidence that are relevant to your team’s response. When completing the items on this assessment, the
team should base its responses on the classrooms being targeted for implementation by the program.
Consensus: Comprehensive Commitment and
Support
Status
Comments/Evidence
1. District/Program level leadership is established and provides
active commitment and support (e.g., meets to review data and
issues at least twice each year).
2. The District/Program Leadership provides opportunities for
training, support and active involvement (e.g., administrator is
actively involved in Leadership Team meetings).
3. The staff support and are actively involved with MTSS/RtI
(e.g., one of top program goals).
4. A District/Program Leadership team is established and
represents the roles of a preschool administrator/ elementary
administrator, teacher, parent )
5. Data are collected to assess level of commitment and impact
of MTSS/RtI on faculty/staff.
6. All personnel have received an overview of the MTSS/RtI
framework and its implications for change from a traditional
instructional model.
7. Families are included in the planning and implementation of
MTSS/RtI.
8. The MTSS/RtI plan is integrated with other program/ district
initiatives (e.g. integrated into K-12 initiatives).
* Adapted from the Florida Problem Solving/Response to Intervention Project and the IL-ASPIRE SAPSI v. 1.6
Center for School Evaluation, Intervention and Training (CSEIT)
Loyola University Chicago, Influences by MiBLSi, IISD,
HISD
3
MTSS Self-Assessment
Scale:
Not Started (N) — (The activity occurs less than 24% of the time)
In Progress (I) — (The activity occurs approximately 25% to 74% of the time)
Achieved (A) — (The activity occurs approximately 75% to 100% of the time)
Maintaining (M) — (The activity was rated as achieved last time and continues to occur approximately
75% to 100% of the time)
Infrastructure Development: Data Collection and
Team Structure
Status
Comments/Evidence
9. District/Program-wide universal screening data (e.g., PELI,
DIBELS, Aimsweb, SRSS, EWS) are collected through an
efficient and effective systematic process.
10. District/Program-wide data are presented to staff after each
benchmarking session (e.g., staff meetings, team meetings,).
11. District/Program -wide data are used to evaluate the
effectiveness of core academic programs.
12. District/Program-wide data are used to evaluate the
effectiveness of core behavior programs.
13. Universal Screening Data (PELI, DIBELS, Aimsweb) data
are used in conjunction with other data sources to identify
students needing targeted group interventions and individualized
interventions for academics.
14. Behavior data (SRSS, SWIS, EWS) are used in conjunction
with other data sources to identify students needing targeted
group interventions and individualized interventions for
behavior.
15. Data are used to evaluate the effectiveness (MTSS/RtI) of
Tier 2
Intervention programs.
16. Individual student data are utilized to determine response
to Tier 3 interventions.
**17. Special Education Eligibility determination is made using
the MTSS/RtI model for the following programs: Early
Childhood Developmentally Delayed (ECDD), Specific
Learning Disabilities (SLD), Speech and Language Impaired
(SLI), Autism Spectrum Disorder (ASD).
**Under Construction
* Adapted from the Florida Problem Solving/Response to Intervention Project and the IL-ASPIRE SAPSI v. 1.6
Center for School Evaluation, Intervention and Training (CSEIT)
Loyola University Chicago, Influences by MiBLSi, IISD,
HISD
4
MTSS Self-Assessment
Scale:
Not Started (N) — (The activity occurs less than 24% of the time)
In Progress (I) — (The activity occurs approximately 25% to 74% of the time)
Achieved (A) — (The activity occurs approximately 75% to 100% of the time)
Maintaining (M) — (The activity was rated as achieved last time and continues to occur approximately
75% to 100% of the time)
Infrastructure Development: Data Collection and
Team Structure (Cont’d)
Status
Comments/Evidence
18. District/Program Leadership/staff have a process to select
evidence-based strategies/practices for Tier 1.
19. District/Program Leadership/staff have a process to select
evidence-based strategies/practices for Tier 2.
20. District/Program Leadership/staff have a process to select
evidence-based strategies/practices for Tier 3.
21. District/Program Leadership/staff have a regular meeting
schedule for problem-solving activities.
22. District/Program Problem Solving Teams evaluates target
students’ needs for MTSS/RtI at regular meetings.
23. The District/Program Leadership team involves families.
24. The District/Program Leadership Team has regularly
scheduled data day meetings to evaluate Tier 1, Tier 2, and Tier
3 data.
* Adapted from the Florida Problem Solving/Response to Intervention Project and the IL-ASPIRE SAPSI v. 1.6
Center for School Evaluation, Intervention and Training (CSEIT)
Loyola University Chicago, Influences by MiBLSi, IISD,
HISD
5
MTSS Self-Assessment
Scale:
Not Started (N) — (The activity occurs less than 24% of the time)
In Progress (I) — (The activity occurs approximately 25% to 74% of the time)
Achieved (A) — (The activity occurs approximately 75% to 100% of the time)
Maintaining (M) — (The activity was rated as achieved last time and continues to occur approximately
75% to 100% of the time)
Implementation: Three-Tiered Intervention System
and Problem-Solving Process
Status
Comments/Evidence
25. The District/Program has established a three-tiered system
of service delivery.
a. Tier 1 Academic Core Instruction/Curriculum clearly
identified.
b. Tier 1 Behavioral Core Instruction/Curriculum clearly
identified.
c. Tier 2 Academic Supplemental Instruction/ Strategies clearly
identified.
d. Tier 2 Behavioral Supplemental Instruction/ Strategies
clearly identified.
e. Tier 3 Academic Intensive Strategies are evidence-based.
f. Tier 3 Behavioral Intensive Strategies/Programs are Evidencebased.
26. Teams (e.g., District/Program/Classroom Problem-Solving
Teams,) implement effective problem solving procedures
including:
a. Universal screening and other assessment data have been
reviewed to determine the percentage of students currently
proficient overall and within each sub-group, and a gap analysis
has been completed.
b. Replacement behaviors are clearly defined.
c. Problem analysis is conducted using available data and
evidence-based hypotheses.
d. Intervention plans include evidence-based (e.g., researchbased, data-based) strategies.
* Adapted from the Florida Problem Solving/Response to Intervention Project and the IL-ASPIRE SAPSI v. 1.6
Center for School Evaluation, Intervention and Training (CSEIT)
Loyola University Chicago, Influences by MiBLSi, IISD,
HISD
6
MTSS Self-Assessment
Scale:
Not Started (N) — (The activity occurs less than 24% of the time)
In Progress (I) — (The activity occurs approximately 25% to 74% of the time)
Achieved (A) — (The activity occurs approximately 75% to 100% of the time)
Maintaining (M) — (The activity was rated as achieved last time and continues to occur approximately
75% to 100% of the time)
Implementation: Three-Tiered Intervention System
and Problem-Solving Process (Cont’d)
Status
Comments/Evidence
e. Intervention support personnel are identified and scheduled
for all interventions.
f. A system is in place to continually verify that interventions
are implemented with fidelity.
g. Response to intervention is evaluated through systematic data
collection.
h. Changes are made to intervention based on student response.
i. Families are routinely involved in implementation of
MTSS/RtI process and interventions.
j. Families are provided information on the MTSS/RtI process,
including an overview of the MTSS/RtI framework, tiered
instruction, types of programs used, and tips to support their
children and school to implement the MTSS/RtI strategy. The
overview includes timelines, explanations of interventions, and
expectations.
k. Families are notified and requested to participate in the threetier process as soon as their children begin tiered supports.
l. Families are involved in their problem solving, progress
monitoring, and goal setting.
m. Families are routinely involved in implementation of
interventions.
* Adapted from the Florida Problem Solving/Response to Intervention Project and the IL-ASPIRE SAPSI v. 1.6
Center for School Evaluation, Intervention and Training (CSEIT)
Loyola University Chicago, Influences by MiBLSi, IISD,
HISD
7
MTSS Self-Assessment
Scale:
Not Started (N) — (The activity occurs less than 24% of the time)
In Progress (I) — (The activity occurs approximately 25% to 74% of the time)
Achieved (A) — (The activity occurs approximately 75% to 100% of the time)
Maintaining (M) — (The activity was rated as achieved last time and continues to occur approximately
75% to 100% of the time)
Implementation: Monitoring and Action Planning
Status
Comments/Evidence
27. A strategic plan (implementation plan) exists and is used by
the District/Program Leadership Team to guide implementation
of MTSS/RtI.
28. The District/Program Leadership Team meets at least twice
each year to review data and implementation issues.
29. The District/Program Leadership Team meets at least twice
each year with the District Leadership Team to review data and
implementation issues.
30. Changes are made to the implementation plan as a result of
program and district leadership team data-based decisions.
31. Feedback on the outcomes of the MTSS/RtI Project is
provided to program-based staff and families at least yearly.
* Adapted from the Florida Problem Solving/Response to Intervention Project and the IL-ASPIRE SAPSI v. 1.6
Center for School Evaluation, Intervention and Training (CSEIT)
Loyola University Chicago, Influences by MiBLSi, IISD,
HISD
8
MTSS Self-Assessment (Cont’d)
Scale:
Not Started (N) — (The activity occurs less than 24% of the time)
In Progress (I) — (The activity occurs approximately 25% to 74% of the time)
Achieved (A) — (The activity occurs approximately 75% to 100% of the time)
Maintaining (M) — (The activity was rated as achieved last time and continues to occur approximately
75% to 100% of the time)
Professional Development (Consensus,
Infrastructure, Implementation)
Status
Comments/Evidence
32. All staff involved in the implementation of MTSS/RtI
receives training in effective use of data for instructional
decision-making.
33. All staff involved in the implementation of MTSS/RtI
receives training in assessment tools used for universal
screening (i.e. PELI, BIR, SRSS, DIBELS, Aimsweb, EWS)
and progress monitoring.
34. All staff involved in the implementation of MTSS/RtI
receives training in research-based intervention strategies.
35. All staff involved in the implementation of MTSS/RtI
receives training in collaborating with and involving families.
36. Key district and program staff are identified for enhanced
training in specific components of MTSS/RtI to build capacity
and to ensure sustainability of MTSS/RtI.
37. To facilitate application of data analysis skills, program
schedule time for staff to review data following universal
screening.
38. The District/Program provides a variety of opportunities
(e.g., printed materials, public meetings) for families to learn
about the three-tiered intervention model using an MTSS/RtI
process.
39. The program professional development calendar provides
sufficient time and flexibility for professional development in
the components of MTSS/RtI.
* Adapted from the Florida Problem Solving/Response to Intervention Project and the IL-ASPIRE SAPSI v. 1.6
Center for School Evaluation, Intervention and Training (CSEIT)
Loyola University Chicago, Influences by MiBLSi, IISD,
HISD
9
Analyze Systems/Process/Fidelity Data for Overall MTSS Implementation
Related to Problem Statement
MTSS Self-Assessment (MTSS-SA)
The MTSS Self-Assessment (MTSS-SA) monitors the extent to which schools are
making progress toward full implementation of MTSS practices. The MTSS-SA
measures progress in consensus, infrastructure, implementation, and professional
development to promote MTSS systems.
What have we done to address areas of the MTSS-SA since last year?
Consensus: Comprehensive Commitment and Support
Infrastructure Development: Data Collection and Team Structure
Implementation: Three-Tiered Intervention System, Problem-Solving Process,
Monitoring and Action Planning
Professional Development: Consensus, Infrastructure, Implementation
List any barriers to improving MTSS consensus, infrastructure, and implementation.
(Record barriers needing district-level support in Appendix E)
 At the building level

At the district level
* Adapted from the Florida Problem Solving/Response to Intervention Project and the IL-ASPIRE SAPSI v. 1.6
Center for School Evaluation, Intervention and Training (CSEIT)
Loyola University Chicago, Influences by MiBLSi, IISD,
HISD
10
Additional Comments/Evidence:
* Adapted from the Florida Problem Solving/Response to Intervention Project and the IL-ASPIRE SAPSI v. 1.6
Center for School Evaluation, Intervention and Training (CSEIT)
Loyola University Chicago, Influences by MiBLSi, IISD,
HISD
11