MILWCOLLEGEPREP
Dean RtI Guiding Questions and Checklist
Student name:______________________________________________________
Teacher who is referring: _________________________________________
Date: ______________
Guiding Questions to talk to the referring teacher with before RtI referral is put in
1) What are the struggles are you having with this student (describe specifics of behaviors or academic
performance)?
2) Have you established a relationship with this student’s family (contacted parent/guardian to discuss
concerns)?
3) Behavior: How often does this behavior occur (think frequency, intensity, duration)?
4) Academic: In what subjects is the student struggling? How is the student struggling (think about the
skills the students is lacking or struggling with)?
5) What interventions have you tried with this student:
Of the five areas listed below, which have been changed in some way in an attempt to address the
concern(s)? Check the area(s) and describe what was attempted. Give duration and describe evidence of
student being successful or not successful.
__ INSTRUCTION: Changing ways the student acquires skills in the classroom
________________________________________________________________________
________________________________________________________________________
__ PRESENTATION: Changing how lessons are delivered and materials are displayed
________________________________________________________________________
________________________________________________________________________
__ MATERIALS: Changing student and teacher materials for instruction
________________________________________________________________________
________________________________________________________________________
__ ENVIRONMENT: Changing the physical learning environment /classroom arrangement
________________________________________________________________________
________________________________________________________________________
__ OUTPUT/RESPONSE: Changing the way the scholar shows what they know
________________________________________________________________________
______________________________________________________________________
What other strategies have you used?
Yes
Not
yet
Strategy attempted
How many minutes per
day?
How many times per
week?
Alternative reading materials (ex: Reading
A-Z)
Study sheets for review and drill
Early Reading Tutor
1:1 with teacher / EA
Increase use of manipulatives
Help from volunteer tutor (adult/peer)
Increase repetition & drill
Skill based learning groups
Increase positive reinforcement
Break assignments into small steps
Frequent checks for understanding
Provide rewards for task completion
Enlist parent to support & review skill at
home
Additional Compass Learning time
Alternative math materials
EA small group support in math or
reading
Daily Check-in
Break time / Cool off time
Sticker Charts
Modification to Classroom Behavior
system
Daily Behavior Reports
Comments:
*Is the teacher using all of the tools available to MCP teachers (Wall Cards, Compass Learning, AR, SRA,
Behavior Management Systems, other teachers suggestions, support from ) with consistency, fidelity, and
for enough time that it could make an impact for this student?
** Decide after this meeting with the teacher if the teacher should continue with the RtI process.
If Yes: Give the teacher the RtI questionnaire to fill out and return to Ms. Breslow’s mailbox
Once you receive an email invite
Bring the following items to the meeting
 Current attendance records from Skyward
 Current deposit records from Skyward
 Most recent report card from Skyward
 Most recent progress report from Skyward
 Current MAP scores
 CUM folder
 This piece of paper