Early Childhood Response to Intervention (RtI) Documentation Form
Updated Fall 2012
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1. Please contact your Mississippi Bend AEA9 Early Childhood Consultant or building
support person each time you begin an RtI form. This notification assists the AEA staff
in supporting you with this process.
2. The RtI form has been updated to better align with the new State of Iowa EER
document. The updated form should allow for better correlation and transfer of
collected data.
3. Remember that the RtI form assists in identifying and documenting concerns as well as
interventions provided in support of students. Concerns brought to preschool staff by
families and Mississippi Bend AEA9 staff must be documented in order to maintain Child
Find compliances.
4. Remember to ATTACH any testing protocol scores, medical information, or GOLD
assessment data with the RtI document when submitting.
Early Childhood Response to Intervention Form
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Early Childhood Response to Intervention (RtI) Documentation Form
Date:
Child’s Name:
Birth Date:
Teacher:
Center:
1. What is your area of concern?
Academic
Behavior
Physical
Health
Hearing/Vision
Communication
Adaptive Behavior
List specific concerns within the checked domain (i.e., academic: colors, counting, following
directions):
2. What evidence suggests the concerns have occurred over time and/or in various settings?
3. What are the child’s strengths that support the child’s educational success in the area(s) of concern?
INTERVENTION PLAN
DOMAIN:
1. When will the intervention start?
2. Who is carrying out the intervention plan?
3. List the GOLD Objectives, Iowa Early Learning Standards or preschool’s adopted curriculum
objectives for the area of concern at the child’s age level:
4. Baseline data (describe in measureable terms what the student is able to do):
5. What is the expected performance for a typical peer in your classroom with regards to this skill?
Early Childhood Response to Intervention Form
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6. Write a SMART goal for the term of that intervention. (i.e. By February 1,when given manipulatives,
Joe will be able to count using one to one correspondence to 5 in 6 out of 10 trials.)
Describe the specific strategies, supports, environmental changes, etc. that will be used in order for the child
to gain this new skill.
How often will this intervention be provided?
7. How and when will progress monitoring be provided?
INTERVENTION FOLLOW-UP
1. Following the intervention, what are the individuals level of performance in comparison to what is expected?
2. If the child received instruction in a group, how was the child’s response in comparison to peers in the same
small group?
3. Identify the instruction, interventions and environmental changes under which the individual experienced the
most growth of success.
Interventions were successful in the general education setting.
Interventions were not successful in the general education setting.
4. What are the next steps?
Early Childhood Response to Intervention Form
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