Warren County Schools
Response to Intervention - Student Data and Referral Sheet
(Complete ONLY for a Tier II student being referred to Tier III!)
Student Last Name, First Name Middle Name
DOB Month / Day / Year
Parent
Male
Address Street City, KY Zip
Phone (
)
School
Grade
Teacher
Female
-
Reason for Referral to Tier III:
Describe Student’s Strengths:
STUDENT RECORD REVIEW – Each area must be addressed OR indicate “As Not Applicable”
(NA)
ATTENDANCE
Days Present Last
Year
TESTING INFORMATION
GRADE
GMADE
Days Absent Last Year
Days Present This
Year
Days Absent This Year
List all schools attended:
DISCIPLINE RECORD
Classroom Discipline Reports
Office Referrals
KCCT
Reading
Suspensions
Math
In School
On-demand writing
Out of School
Other (Lexile, Quantile, ACT, etc.):
Total Number of Days
Other Information:
Any retentions (what
grade):
ACADEMIC GRADES
Reading
Math
Writing
Science
Soc. Studies
SCREENING INFORMATION
Speech
Date
Hearing
Date
Vision
Date
Results
Recheck Needed
Results
Recheck Needed
Results
Recheck Needed
Other
1
SPECIAL CONCERNS
Medical History, Health
Conditions, Social/Family,
etc.
ELL
Title 1
CURRENTLY RECEIVING
Special Education
Gifted Ed
Occupational Therapy
Physical Therapy
Speech/Language Therapy
Tutoring
Mental Health Counseling
Other:
Teacher Observations
For each area, rate the student in comparison to classmates using a scale from 0 – 5. If NA – use 0, in lower
10% use-1; below average use-2; average use-3; above average use-4; in highest 10% use-5).
0 Basic Reading Skills
0 Follows Directions
0 Reading Comprehension Skills
0 Functions Independently
0 Basic Math Skills
0 Attends to Class Work
0 Math Reasoning Skills
0 Completes Assignments
0 Written Language Skills
0 Motivation and Effort
0 Handwriting Skills
0 Organizational Skills
0 Spelling Skills
0 Motor Coordination
0 Receptive Language
0 Relates Well with Peers
0 Expressive Language
0 Relates Well with Adults
0 Retention of New Information
Notes:
Document Attempts to Meet Student Needs within the Regular Program
Indicate below the strategies/interventions used over a reasonable time period in response to this student’s
problem(s).
Tier I/Core Interventions
Alternative Reading Materials
Provide Study Sheet for Review
Flexible Small Groups (Teacher Directed)
Cooperative Learning Groups
Individualized Reading Instruction
One-on-one With Teacher
Increased Use of Manipulatives
Help From Parent/Volunteer,
Tutor/Paraeducator
Alternative Math Materials
Increase Repetition and Drill
Skill-based Learning Groups
Programs Utilized:
Scott Foresman Reading Streets
SRA Reading Mastery
Houghton Mifflin
Go Math!
Math in Focus
Do the Math
PBIS Guidelines to Success
CHAMPS teaching of expectations
Other
Other
Other
2
Additional Use of Graphic Organizers
Other
Increase Positive Reinforcement
Break Assignments Into Small Steps
Other
Notes:
Frequent Feedback by Teacher
Provide Rewards for Task Completed
Enlist Parent Support to Review Skills at Home
Using formative assessments
to guide instruction
Other:
Other:
Other:
Other:
Tier II/Supplemental Interventions
Instructional Grouping
small group instruction
individual instruction
peer, cross-age tutor
flexible grouping
Teacher Delivery
graphic organizers
differentiated questioning
strategies
team teaching
allowing alternative
methods of demonstrating
knowledge
communicating expectations
student engagement
strategies
allowing extended time
facilitating independence
insuring intensity of
instruction
requiring skill mastery
reteaching skills when
needed
alternative grading criteria
Computer Software
Study Island
Fraction Nation
FASTT Math
Earobics
Read 180
Organizational Techniques
assignment notebook
materials checklist
Supplementary Tools
providing notes to student
providing study guides
calculator
computer-aided
instruction
manipulatives
Motivational Techniques
student goal setting
contracts
progress reports
graphing of progress
Environment
study area
preferential seating
altered schedule
Instructional Strategies
direct instruction
repeated readings
highlighted materials
study skills instruction
shortened assignments
modified objectives
supplemental instruction
alternative materials
Behavioral Strategies
reteaching expectations
prompt expected
behavior
rewards for expected
bhvr
behavioral contract
systematic feedback
practice expected bhvr
self-management program
progress charting
social skills group
visual schedule
mentoring
check in/check out
use of time-out
loss of privileges
referral to counselor
contacts with home
meeting with parents
office referral(s)
Instructional Programs
Sidewalks
Soar to Success
Corrective Reading
Number Worlds
One to One Math
Do the Math
Second Step
3
(parallel curriculum)
OTHER
TIER II DECISION POINT
After at least 6-8 weeks, did the student respond to intervention attempts?
Yes
No
YES
NO
Continue with interventions and progress
monitoring in Tier II and reassess in six weeks
OR return to Tier I if sufficient progress is made
and reassess with next benchmark
Refer student to Tier III and complete Tier III
Problem Solving Intervention Plan with RTI team
Teacher Signature _________________________________ Date ________________________
4
RtI Conference Notes
Committee Decision:
Begin Tier
Intervention in the area of
Continue Tier
Intervention in the area of
Change frequency of current intervention to
Change size of group to
Try new intervention:
Move to Tier
Intervention
Goal/Benchmark reached. Discontinue interventions.
Refer for evaluation for special education eligibility.
Other, specify:
Next Problem-Solving Meeting Date:
Name
Signatures of Committee Members
Role/Relationship
5