Warren County Schools

Warren County Schools Middle/High School

Response to Intervention - Student Data and Referral Sheet

(Complete ONLY for a Tier II student being referred to Tier III!)

Student Last Name, First Name Middle Name

Parent

Address Street City, KY Zip

School

DOB Month / Day / Year

Male Female

Phone () -

Grade Teacher

Reason for Referral to Tier III:

Describe Student’s Strengths:

STUDENT RECORD REVIEW – Each area must be addressed OR indicate “As Not Applicable” (NA)

ATTENDANCE
Days Present Last Year
Days Absent Last Year
Days Present This Year
Days Absent This Year
List all schools attended:
Any retentions (what grade): / TESTING INFORMATION
GRADE GMADE
K-PREP
Reading Math
On-demand writing
Lexile
EXPLORE/PLAN/ACT (circle)
English Math Reading
Science Composite
Other (Quantile, End of Course, etc.): / DISCIPLINE RECORD
Classroom Discipline Reports
Office Referrals
Suspensions
In School
Out of School
Total Number of Days Other Information:
**Attach SWIS data
ACADEMIC GRADES
**Attach transcript and current grades from Infinite Campus / SCREENING INFORMATION
Speech
Date Results Recheck Needed
Hearing
Date Results Recheck Needed
Vision
Date Results Recheck Needed
Other
Language Spoken in the home:
SPECIAL CONCERNS
Medical History, Health Conditions, Social/Family, etc. / CURRENTLY RECEIVING
ELL Title 1 Special Education Gifted Ed
Occupational Therapy Physical Therapy
Speech/Language Therapy Tutoring
Mental Health Counseling
Other:

Teacher Observations

For each area, rate the student in comparison to classmates using a scale from 0 – 5. If NA – use 0, in lower 10% use-1; below average use-2; average use-3; above average use-4; in highest 10% use-5).

012345 Basic Reading Skills
012345 Reading Comprehension Skills
012345 Basic Math Skills
012345 Math Reasoning Skills
012345 Written Language Skills
012345 Handwriting Skills
012345 Spelling Skills
012345 Receptive Language
012345 Expressive Language
012345 Retention of New Information / 012345 Follows Directions
012345 Functions Independently
012345 Attends to Class Work
012345 Completes Assignments
012345 Motivation and Effort
012345 Organizational Skills
012345 Motor Coordination
012345 Relates Well with Peers
012345 Relates Well with Adults
Notes:

Document on the following table attempts to meet the student’s needs within the regular program.

Indicate below the strategies/interventions used over a reasonable time period in response to this student’s problem(s)

Tier I and Tier II Interventions Implemented
Instructional Grouping
Small group instruction
Individual instruction
Cooperative Learning Groups
Peer, cross-age tutor
Flexible grouping
Teacher Delivery
Differentiated questioning
strategies
Team teaching
Allowing alternative
methods of demonstrating
knowledge
Modified learning objectives
Supplemental instruction
Shortened assignments
Communicating expectations
Student engagement
strategies
Allowing extended time
Facilitating independence
Insuring intensity of instruction
Requiring skill mastery
Reteaching skills when
needed
Alternative grading criteria
Breaking assignments into small
steps – chunking
Frequent feedback by teacher
Enlist parent support to review
skills at home
Increased repetition and drill
Use of alternative math
materials
Use of alternative reading
materials
Help from parent/volunteer or
tutor/paraeducator
Computer Software
ePrep
Math XL
Zoom Math
System 44
Read 180 / Organizational Techniques
Assignment notebook
Materials checklist
Locker checks
Research-based
Strategies
Direct instruction
Study skills instruction
Reciprocal learning
Task rotations
Formative assessments
Graduated difficulty
strategy
Use of matrix, flow charts,
diagrams for instruction
Use of KWL Charts (Know, Want to know, Learned)
Student generated Flip Charts
Use of mneumonic devices
Word banks
Visualizing vocabulary
Think-Pair-Share
Thoughtful Ed. Strategies (i.e., Reading for Meaning; Compare/Contrast; Three Column Notetaking)
Graphic organizers
Literacy-specific Strategies
Repeated readings
Active reading
strategies (e.g., Annotating
Text, Questioning the
Author, etc.)
Vocabulary strategies
Use of anticipation guides / Behavioral Strategies
PBIS Guidelines to Success
Reteaching expectations
Prompt expected behavior
Rewards for expected bhvr
Behavioral contract
Systematic feedback
Practice expected bhvr
Self-management program
Progress charting
Social skills group
Visual schedule
Mentoring
Check in/check out
Loss of privileges
Referral to counselor
Contacts with home
Meeting with parents
Office referral(s)
Environment
Study area
Preferential seating
Altered schedule
Motivational Techniques
Student goal setting
Contracts
Progress reports
Graphing of progress
Accelerated Learning Classes
ACT transition course - English/Reading or Math (circle)
Study Skills
College and Career
Readiness:
Supplementary Tools
Providing notes to student
Providing study guides
Calculator
Manipulatives
Use of technology (i.e., Alpha Smart, Neo, etc.)
OTHER

TIER II DECISION POINT

After at least 6-8 weeks, did the student respond to intervention attempts? Yes No

Guiding questions: Is there a motivational versus performance deficit? Should an alternative method/approach be utilized (e.g., remain in an elective class as opposed to adding a reading/math intervention, would a performance-based credit or alternative setting such as Lighthouse, etc. be an option)? What can be done to prevent the student from dropping out? Should a contract be done with the student?

YES / NO
Continue with interventions and progress monitoring in Tier II and reassess in six weeks OR return to Tier I if sufficient progress is made and reassess with next benchmark / Refer student to Tier III and complete Tier III Problem Solving Intervention Plan with RTI team

Teacher Signature ______Date ______

RtI Conference Notes

Committee Decision:

Begin Tier Intervention in the area of

Continue Tier Intervention in the area of

Change frequency of current intervention to

Change size of group to

Try new intervention:

Move to Tier Intervention

Goal/Benchmark reached. Discontinue interventions.

Refer for evaluation for special education eligibility.

Other, specify:

Next Problem-Solving Meeting Date:

Signatures of Committee Members

Name Role/Relationship