BROWNSVILLE INDEPENDENT SCHOOL DISTRICT
RESPONSE TO INTERVENTION PROCESS
MEETING MINUTES AND ACTION LOG
Student:
DOB:
ID#:
Gr.:
Campus:
Person(s) making request for the RtI core team review:
Date:
EVALUATION AND ELIGIBILITY DOCUMENTATION:
I. REVIEW OF AVAILABLE INFORMATION (INCLUDE TEST SCORES WHEN APPROPRIATE)
1.
Summarize present levels of performance in areas evaluated for consideration of need.
2.
Teacher reports/comments: (Information provided should be educationally relevant. Data must include
written documentation of curriculum-based monitoring and student comparison to peers.)
3.
Areas of concern: (i.e., behavior, academic, medical/health, at-risk for dyslexia, etc. – Be specific!)
4.
Health and development: (include information available from school nurse and/or parent – Form RTI-2.
Health information must be current for present school year.)
5.
Data reviewed and/or considered by the RtI core team:
Samples of student work
Student profile
Health/medical report
Parent information
Formal tests (aptitude, etc.)
Grades
Cumulative folder (copy)
Discipline records (copy)
Progress reports
TAKS reports (copy)
RtI Student folder
Teacher recommendations and/or
observations
Adaptive behavior checklists
Individualized reading tests
Learning style inventories
Results of Speech screening
Anecdotal reports
Spec. Educ. FIE report
(copy/summary)
Other:
6.
Further information needed?
Yes
(a)
If Yes, what information is needed?
(b)
Person responsible for obtaining information:
(c)
Date, time and place to reconvene committee:
No
9-2009
II. ELIGIBILITY DECISION:
Student data indicates a need for academic and/or behavioral interventions through Tier 2 of the
RtI process. IIP (Form RtI-5) must be completed.
Student data indicates student demonstrates need for more intensive interventions through Tier 3
of the RtI process. Referral to Tier 3 or Section 504 (only if there is a suspected disability) shall
be initiated. (Specify Tier 3 or §504)
Student data indicates student demonstrates little to no response to intervention through either
Tier 2 or Tier 3 of the RtI process. Referral to Tier 4 Special Education shall be initiated.
Student data indicates that there is no need for academic or behavioral interventions. Student will
be monitored on a regular basis for any changes in need.
NOTES:
RTI CORE TEAM MEMBERS’ SIGNATURES:
_________________________________________
________________________________________
RtI Chair
Case Manager
_________________________________________
________________________________________
Administrator or Designee
Counselor
_________________________________________
________________________________________
Special Education Teacher/Specialist
Teacher
_________________________________________
________________________________________
Other
Other
COMPLETE SUMMARY OF ACTIONS TAKEN ON NEXT PAGE
9-2009
III.
SUMMARY OF ACTIONS TAKEN BY RTI CORE TEAM:
PLAN (CODE)
NOTES
FOLLOW-UP DATE
Plan Codes:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Attendance Office Referral
Classroom Observation
Community resource
Differentiated Instruction
Dyslexia Screening Checklist
Exit from RtI Services
Gear Up
Home Visit
Instructional Intervention Plan
LEP Screening
Mentor
Need More Information
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
No Action Needed
Nurse
Parent Refused Services
Parent/Guardian Conference
Parental Involvement specialist
Peer Helper
Personal Graduation Plan
Positive Behavior Support Plan
Re-entry Transition
Request §504 Referral
Request Dyslexia Evaluation
Request Special Education FIE
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
Schedule Change
School Counselor/Group
Speech Screening Checklist
Student Refused Services
Summer School
TAKS Tutorials
Tier 2 Reading Interventions
Tier 3 Reading Interventions
Tutoring
Withdrew from School
Withdrew to AEP or JJAEP
Other:
9-2009