Form 1
Response to Instruction and Intervention
Tier 1
Student Name:
Date of Enrollment:
Grade:
Teacher:
Building:
Primary Concerns
What are the primary concerns for this child:
____________________________________________________________________________________
________________________________________________________________________________
What data was reviewed to cause this concern (please bring copies of data):
____________________________________________________________________________________
________________________________________________________________________________
Parent Communication (Required before referring student to RTI team meeting)
Date of communication with parent regarding this student’s issue: ____________________________
What was the plan of action as a result of this conversation:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Tier 1 Accommodations
Available supports to all students within the classroom setting/curriculum as needed. Please indicate
what accommodations were implemented in your classroom and/or check which accommodations will
be implemented.
Date(s)
Implemented:
Missing assignments/weekly check-in
Quiz / test corrections
Quiz and/or test retakes
Redo/Resubmit assignments not meeting student potential
Used extended time on tests and assignments
Projects & long-term assignments chunked
Positive phone call/email home
Conference with parents before interims go home
Paired with positive peer role models
Ongoing academic goal setting with teacher
Directed Flex/Intensive Study Hall
Guided notes
Reducing number of assessed items
Accepted late work
Preferential seating
Behavior Contracting
Student name:
Form 1
Technology Supplemental use (For example, Read/Write 4 Gold, Spell Check, and so on)
Scribe
Change of test format (i.e., fill in the blank to matching or multiple choices)
Use of Writing Template/Graphic Organizers for writing/reading
Use of Graphic Organizers for solving math problems
Other:
Tier 1 Interventions/Strategies
Please indicate if prior interventions were implemented and the results and/or check which
interventions will be implemented.
Date(s)
Implemented:
______
Explicit pre-teaching of concepts ___x weekly (Circle Subject Area: MATH LA SS SCI)
______
Explicit re-teaching of concepts ___x weekly (Circle Subject Area: MATH LA SS SCI)
______
Before/After School Study Group
______
Differentiation
______
Co-teaching
______
Guided small group instruction
______
Accommodations:
______
Explicit modeling
______
Flexible grouping
______
Graphic organizers
______
Integrating reading and writing across the curriculum
______
Formative assessments
______
Scaffolding
______
Behavior contracting
______
Technology and software
______
Fluency practice
______
Optional academic learning labs
______
Peer Collaborators
______
Optional Office Hours
______
Other:
Results of Tier 1 Accommodations/Interventions (may be completed at/or prior to meeting)
Baseline Data
Goal
Intervention/Accommodation Data Resulting from
Intervention/Accommodation
Follow-up Date:
Student name: