NHCS Tier 1 RtI & Behavior Checklist
Before the Meeting
Teacher sets up conference with parent.
Document every phone attempt on parent and teacher participant log document. RTISST Participants Log
* If parent is not available for conference in person or by phone, teacher can complete K-8
PEP documentation without parent involvement.
During the Meeting
At conference, have each participant sign participant page (if a phone conference,
write parent’s name under participants on the tracking form, sign in page).
Complete K-8 PEP documentation. Teacher will need student’s module record(s) to
document accurately. K-8 PEP
Identify target behavior(s). Some examples provided below:
__ Hands and feet to self
__ Decrease motor disruption
__
__ Remain in assigned area
__ Appropriate language use
__
__ Complete assignments
__ Follow directions with prompts
__
Select a measurable goal.

100% Behavior goal is or may be harmful to self and/or others.
 75% Behavior goal is NOT harmful to self and/or others.
Identify an intervention plan (consult the sortable protocol).
Select measures for collecting data. Some examples provided below:
__ Daily conduct grades
__ Office referrals
__ Suspensions
__ Time removed from instruction
__
__
Hearing and vision screening. If a student has not had a hearing and vision screening
within one year, an update needs to occur. Hearing and Vision Screening
Documentation
Schedule a follow-up meeting with parent 4 weeks later. (If behavior is more severe or
worsens, you may consider meeting sooner.)
After the Meeting
Make sure a copy of the K-8 PEP is provided to parents, and keep a copy for teacher
records and Module 2 of the Student’s Record.
Implement interventions and collect data.
During Follow-up Meeting
Hold K-8 PEP review meeting to review the results, and document on K-8 PEP
documents.
Document results using quantifiable measures. (e.g., numbers and percentages)
___ Continue – if research-based interventions are effective and student is making
progress towards the goal (student will remain at Tier I).
___ Modify – if research-based intervention can be modified to increase effectiveness
and student is responding somewhat to the intervention but progress is minimal
(student will remain at Tier I).
___ Discontinue – if interventions were successful and no longer needed.
___ Move to Tier II if student does not appear to be responding to research-based
interventions, student may require more intensive interventions to be successful.
___ Place all documentation in Module 2 of the Student’s Record.
Created 4/30/12
NHCS Tier 2a RtI & Behavior Checklist
Before the Meeting
Teacher sets up conference with parent.
Complete parent invitation to conference. Give one copy to the parent, maintain the
original invitation in the Module 2 of the Student’s Record. Parent Invitation to SST
Conference (PSM/RtI)
Document every phone attempt on parent and teacher participant log document. RTISST Participants Log
* If parent is not available for conference in person or by phone, please inform grade level
case manager. Other arrangements may need to be made in order to bridge the connection
between home and school.
During the Meeting
Review K-8 PEP and results.
Complete Tier 2a documentation. RTI-Intervention Plan 2a
Identify target behavior(s). Some examples provided below:
__ Hands and feet to self
__ Follow class rules
__
__ Remain in assigned area
__ Appropriate language use
__
__ Complete assignments
__ Follow directions with prompts
__
Select a measurable goal.

100% Behavior goal is or may be harmful to self and/or others.
 75% Behavior goal is NOT harmful to self and/or others.
Identify an intervention plan (consult the sortable protocol).
Select measures for collecting data. Some examples provided below:
__ Daily conduct grades
__ Office referrals
__ Suspensions (ISS or OSS)
__ Time removed from instruction
__ Daily behavior chart
__ Bounce logs
__ Observations from other staff
__ Percentage of goal met
__ Time on task analysis
__
__
__
Schedule a follow-up meeting with parent 4 weeks later. (If behavior is more severe or
worsens, you may consider meeting sooner.)
After the Meeting
Make sure a copy of the Tier 2a document is provided to parents, and keep a copy for
teacher records and Module 2 of the Student’s Record.
Implement interventions and collect data.
Created 4/30/12
NHCS Tier 2b RtI & Behavior Checklist
Before the Meeting
Teacher sets up conference with parent.
Complete parent invitation to conference. Give one copy to the parent, maintain the
original invitation in Module 2 of the Student’s Record. Parent Invitation to SST
Conference (PSM/RtI)
Document every phone attempt on parent and teacher participant log document. RTISST Participants Log
* If parent is not available for conference in person or by phone, please inform grade
level case manager. Other arrangements may need to be made in order to bridge the
connection between home and school.
Invite other participants to the conference as needed (for example):
Social Worker
Administrators
Community Case Manager
Nurse
Probation Officer
School Psychologist
IBS Teacher
Grade Level Case Manager
504 Coordinator
Counselor
PSM Coordinator
Behavior Specialist
Special Education Liaison
During the Meeting
Review K-8 PEP, Tier 2a plan and results.
Complete Tier 2b documentation. RTI-Intervention Plan Review 2b
 Use quantitative measures for evaluating student’s success.
During the meeting consider the following:
 Consult the sortable protocol
 Gather more information through Social and Developmental History
document
 Collect more data through an FBA/BIP Functional Behavioral Assessment
(FBA) Behavior Intervention Plan (BIP)
 Complete mental health referral
 504 Plan
 Obtain a Mutual Exchange of information Disclosure of Student Records
(Mutual Exchange of Information)
Determine the next step in the RtI process:
___ Continue – if research-based interventions are effective and student is making progress
towards the goal (student will remain at Tier 2).
___ Modify – if research-based intervention can be modified to increase effectiveness and
student is responding somewhat to the intervention but progress is minimal (student will
remain at Tier 2).
___ Move back to Tier 1, if interventions were successful and met the goal but Tier 1 support
is needed.
___ Move to Tier 3 if student does not appear to be responding to research-based interventions,
student may require more intensive interventions to be successful.
___ Place all documentation in Module 2 of the Student’s Record.
Schedule a follow-up meeting with parent 4 weeks later. (If behavior is more severe or
worsens, you may consider meeting sooner)
Develop an Action Plan. (Who is responsible for what?)
After the Meeting
Make sure a copy of the Tier 2b document is provided to parents, and keep a copy for
teacher records and Module 2 of the Student’s Record.
Implement interventions and collect data.
Created 4/30/12
NHCS Tier 3 RtI & Behavior Checklist
Before the Meeting
Gather baseline for target behaviors. Methods of data collection.
__ Tier 2a & b documentation __ FBA data __ Additional data collection (Min. 5 days)
__
__
__
Request an observation:
 Building staff (e.g., counselor, social worker, psychologists, IBS teacher)
 District Level staff (e.g., Liaison, Behavior Support Specialist)
Complete parent invitation to conference. Parent Invitation to SST Conference (PSM/RtI)
Document every phone attempt on parent and teacher participant log document. RTI-SST
Participants Log
* If parent is not available for conference in person or by phone, please inform grade level
case manager. Other arrangements may need to be made in order to bridge the connection
between home and school.
Invite all PSM team members to the conference.
Information for Tier 3a&b documentation may be recorded prior to the meeting
Tier 3 activities will involve more than one meeting.
During the Meeting
Review K-8 PEP, Tier 2a & b plan and results.
Review baseline data.
Revise FBA/BIP/Crisis Plan.
Review/modify target behavior(s). Some examples provided below:
__ Hands and Feet to self
__ Remain in assigned area
__ Complete assignments
__ Follow class rules
__ Use appropriate language
__ Follow directions w/ prompts
__
__
__
Complete Tier 3 documents (3a&b, 3c). Define the Problem/Develop the Assessment Plan
IIIa&b ; Analysis of Assessment Plan 3c
Develop Tier 3 interventions. Develop Intervention Plan 3d
 Consult the sortable protocol .
 Emphasis should be placed on teaching replacing behaviors.
 Interventions at Tier 3 should resemble IEP services and may involve special
education staff.
Select measures for collecting data. Some examples provided below:
__ Daily conduct grades
__ Office referrals
__ Suspensions
__ Time removed from instruction __ Daily behavior chart
__ Bounce logs
__ Observations from other staff
__ Percentage of goal met __ Time on task analysis
Develop an Action Plan
 Who is responsible for intervention?
 Who is responsible for progress monitoring data collection?
 Who is responsible for graphing and analysis?
 Who is responsible for disseminating the student’s plan?
 Who is responsible for documenting intervention changes? (Tier 3e)
Schedule a follow-up meeting with parent 4 weeks later. (If behavior is more severe or
worsens, you may consider meeting sooner)
 Complete Analysis of Intervention Plan 3f
After the Meeting
Make sure a copy of the Tier 3 document is provided to parents, and keep a copy for teacher
records and Module 2 of the Student’s Record.
Implement interventions, progress monitor daily, and review student progress weekly.
Consult Behavior Criteria in Adverse Effect, Specially Designed Instruction & Conditions to
Rule Out document for when intervention changes are appropriate in consideration of special
education eligibility.
Created 4/30/12