This form is for the use of inputting Data into the RtI/AIMSweb system.
RtI Intervention Team Referral
Student Name:___________________________________________ Date : __________
Date of Birth: ___________________
School: _______________________________
Grade Level: _________ Parent/Guardian Name _______________________________
Address: _______________________________________________________________
Phone: (H)_________________ (W) ________________ (C) ____________________
Preparing staff member: __________________________________________________
Name of other Staff who regularly work with this student and who have been consulted in
the problem solving process: _______________________________________________
Student is having difficulty achieving in the classroom due to:( attach referral
checklist)
( ) Academic Skills
( ) Academic Performance ( ) Behavioral Concerns
( ) Attendance/tardy
Specific Concerns in observable terms if possible: _________________________
_________________________________________________________________
P
L
A
N
1. Check the student’s cumulative file. Has he/she been considered for
Interventions in the past? ( ) Yes ( ) No If yes, when? _______________
______________________________________________________________
2. Provide a specific, concrete description of the concerns you have for this
student. Describe the concerns in observable terms:__________________
________________________________________________________________________
3.
What is the duration of the problem?
( ) 1 – 3 Months
Revised 9/15/06
( ) Less than 1 month
( ) 3 – 6 Months
( ) 6 months or longer
CB/JGO
This form is for the use of inputting Data into the RtI/AIMSweb system.
Complete the PDSA process for each concern:
Concern
Strategies/Interventions Dates
Tried List Specific
Implemented
Programs & Strategies
P
L
A
N,
Student
Response (Use
data points when
available)
cont.
DATE:
ASSESSMENT AND RESULTS
CSAP Reading _____________ CSAP Writing _______________
CSAP Math ________________ CSAP Science _______________
TERRA NOVA
Fall _____________
Spring _______________
STAR
DIBELS ________________ TOWRE ____________________
SRI _________________
Other _______________________________________________________
_______________________________________________________
Revised 9/15/06
CB/JGO
This form is for the use of inputting Data into the RtI/AIMSweb system.
GRADE LEVEL TEAM DISCUSSION (must include special education provider)
Meeting
Date
Strategies/Interventions to be
Implemented (include those
responsible to implement the
interventions)
D
O
Estimated Frequency &
Duration Timeline to
Determine Progress
Team signatures____________________________________________________________
_________________________________________________________________________
Special Education Provider signature ___________________________________________
S
T
U
D
Y
ON-GOING DATA COLLECTION AND ANALYSIS OF INTERVENTIONS
After strategies were implemented, is the Problem-Solving Team meeting
necessary? ( ) Yes ( ) No
If no, document the changes implemented and the results (include data and record in
RtI/AIMSWeb.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Data Process terminated: ___________________________________________
If yes to Study Question, continue to next page.
Revised 9/15/06
CB/JGO
This form is for the use of inputting Data into the RtI/AIMSweb system.
PROBLEM SOLVING TEAM INTERVENTIONS:
Contact Parents – Please document all contacts made with parents regarding the
concerns
A
C
T
I
O
N
Dates of contact
Nature of Discussion
Parent Reaction
PST Meeting
Dates
Strategies/Interventions tried –
list specific programs &
strategies
Student Response to the
interventions tried (use data
points when available,
update testing)
Describe any additional interventions that will be implemented as a result of the
discussions with parents and team members: ____________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Revised 9/15/06
CB/JGO
This form is for the use of inputting Data into the RtI/AIMSweb system.
Team Member Name
Team Member Signature
Position
Date
COMPLETE THE REMAINDER OF THE ACTION PLAN
THOROUGHLY, AND MAKE A COPY FOR YOUR
RECORDS, THEN TURN IN THE COMPLETED FORM TO
THE COORDINATOR.
Revised 9/15/06
CB/JGO