MURRAY COUNTY SCHOOLS
TIER 3
RTI Referral Checklist
Student: _______________ DOB _______ Grade _________
Teacher ____________
Item

Hearing & Vision Permission to Screen

Permission to Screen Speech and Language skills


Hearing & Vision Screening provided by School Nurse.
Kindergarten students should have in perm. record. Make sure it
will not expire during Tier 3. If so, get permission to re-screen.
Speech and Language Screening completed.

RTI Coordinator notified of movement into Tier 3

Parent invitation to meeting #1 (Add date sent to parent)

Meeting #1 with parent, teacher, CIF, and SLP if student failed
speech/language screening
Baseline data from teacher is required. Provide Background
Information Forms and/or Physician’s Report to parent.






Background Information-Sent home? ___________
If there are medical needs:
Physician’s report sent home?_________________
Signed?__________________
Meeting #2 with parent, teacher, & RTI Coordinator to review data
collected during 4 week period. SLP should also attend to review
speech/language interventions if implemented.

Data Collection: 4 week period Documentation required; bring
data to Meeting #3

Parent invitation to meeting #3

Meeting #3 with parent, teacher, & RTI Coordinator to review data
collected during 4 week period. SLP should also attend to review
speech/language interventions if implemented.
Data Collection: 4 week period Documentation required; bring
data to Meeting #4. *Make sure hearing/vision is within 1 year
before moving to next meeting.
Parent invitation to meeting #4



HEARING DATE:
VISION DATE:
PASS
FAIL
PASS
FAIL
PASSED?
FAILED?
Date speech/language interventions provided
to teacher_________________
Was Background
Information
Returned?
Returned
Date
Returned
Yes
Was the Physician’s
Report returned?
Date
Returned
Date
faxed to
doctor
No
Data Collection: 4 week period. Documentation required; bring
data to Meeting #2
Parent invitation to meeting #2


Date of Completion
Meeting #4: Data Evaluation Meeting (with parent, teacher, RTI
Coordinator, SLP, and school psychologist to review data collected
during the RTI process and to determine next steps)
Please indicate if S/L teacher will evaluate
Tier 1: 8 weeks Tier 2: 10 weeks Tier 3: 12 weeks



IF REFERRING TO ESS, RTI COORDINATOR
SHOULD HAVE 009 FORM SIGNED BY PRINCIPAL
REFERRAL MADE
NOT REFERRING
Yes
No
If student response to intervention is successful, continue interventions and increase the goal.
If student response to intervention is unsuccessful, change the intervention or goal and determine date for follow-up meeting.
If a student is making adequate progress at any level, he or she can move up and down the pyramid (Tiers of Intervention) in a
continuum of services at any time. If the student makes adequate progress and moves from Tier 3 back to Tier 2, RTI meetings are no
longer necessary, and the student will be monitored by the CORE team for continued progress.
REVISED 2011