(PRONG 1): DOCUMENTATION OF APPROPRIATE INSTRUCTION
Initial Referral & Reevaluation
_______________ has received standards-based Tier I core instruction in the areas of Reading, Math, and
Behavior in the regular education setting, in his/her primary language by a highly qualified teacher.
In addition to core instruction, __________ has received Tier II intervention in the area of __________ for _____ minutes per day, _____ days per week, for _____ weeks using the following research-based strategies: _________________. The intervention goal for Tier II is _________________________ . The
Rate of Improvement (ROI) for the goal is ___________________.
In addition to Tier II instruction, ___________ also received Tier III intervention in the area of
__________ for _____ minutes per day, _____ days per week, for _____ weeks using the following research-based strategies: ___________________________. The intervention goal for Tier III is
_______________________ The Rate of Improvement (ROI) for the goal is _____________________
A special education referral/reevaluation was initiated by the __________. The special education referral
__________ for an out-of-state special education transfer student. Other information, in-state transfer, etc. (as appropriate) ___________________.
ADDITIONAL STATEMENT: REEVALUATION ONLY: (one for the area of reading if needed; one for the area of math if needed; one for the area of behavior if needed.
The student also received specially designed instruction in the area of _______________ which includes the scientifically researched-based strategies of __________________________________ for ________ minutes per day, __________ days per week for __________ weeks/months, etc.) from current and previous IEPs.
The student also received specially designed instruction in the area of _______________ which includes the scientifically researched-based strategies of __________________________________ for ________ minutes per day, __________ days per week for __________ weeks/months, etc.) from current and previous IEPs.
The student also received specially designed instruction in the area of _______________ which includes the scientifically researched-based strategies of __________________________________ for ________ minutes per day, __________ days per week for __________ weeks/months, etc.) from current and previous IEPs.

(PRONG 2): DOCUMENTATION OF APPROPRIATE INSTRUCTION
All Initial Referrals; Reevaluation – (SLD only) completed by General Education
For Tier I reading , the problem solving team used the ______________ for monitoring _______ .
The dates and results of the assessments were __________________. Results of progress monitoring were sent home to the parents on _____.
For Tier I math , the problem solving team used the ______________ for monitoring _______ .
The dates and results of the assessments were __________________. Results of progress monitoring were sent home to the parents on _____ .
For Tier I behavior (if appropriate) , the problem solving team used the ______________ for monitoring
_______ .
The dates and results of the assessments were __________________. Results of progress monitoring were sent home to the parents on _____.
A Parent Letter (J-1) explaining the initiation of Tier II intervention was sent home on _____ . For progress monitoring of Tier II intervention in the area of _____, the problem solving team used the
________ for monitoring. The dates and results of the assessments were __________. The “Rate of
Improvement” (ROI) for Tier II intervention was ________________ A Parent Progress Report Letter (J-
2) was sent home _____ . Tier II intervention will ______________________. The parent was first informed of their right to request an evaluation for special education on _____.
A Parent Letter (J-1) explaining the initiation of Tier III intervention was sent home on _____. For progress monitoring Tier III intervention in the area of _____, the problem solving team used the
________ for monitoring. The dates and results of the assessments were __________. The “Rate of
Improvement” (ROI) for Tier III intervention was ________________. A Parent Progress Report Letter
(J-2) was sent home _____ (list dates). Tier III intervention will __________. The parent was informed of their right to request an evaluation for special education on ______.
A special education referral or reevaluation was initiated by the __________. The special education referral __________ for an out-of-state special education transfer student. Other information (as appropriate) ___________________.
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SUMMARY of BASC-SOS - (Initial Referral Only)
Date: ____________________
Completed by GENERAL EDUCATION
Part A: List of “FREQUENTLY OBSERVED” behaviors checked
Part B: List of behaviors with 4 or more checks
Part C: Summary of Teacher Techniques to change student behavior
RECORD REVIEW (Initial Referral & Reevaluation)
Completed by GENERAL EDUCATION
Summary of State/District Assessments (Name/Results): ________________
Most Current Progress Report/Report Card: Quarter _______: Date _____: Days Absent _____:
Subject/Grades _____: Discipline _____________.
Summary of Work Samples: Subject ________: Area of concern _________: Date ______:
Name of Work Sample __________: Grade ______: “statement” of performance concern __________:
Summary of Work Samples: Subject ________: Area of concern _________: Date ______:
Name of Work Sample __________: Grade ______: “statement” of performance concern __________:
Summary of Work Samples: Subject ________: Area of concern _________: Date ______:
Name of Work Sample __________: Grade ______: “statement” of performance concern __________:
______________________________________ _________________
Signature of School Administrator OR
Home-school/Private School liaison
Date