Minidoka County School District #331

Elementary Data Sheet

Student Name:DOB:

Teacher:Grade:

School Year: Referral Date:

Home Language Survey: If Spanish,complete the WIDA accessbelow?

Assessments / Fall / Winter / Spring / Fall / Winter / Spring / % of typical peers meeting proficiency
IRI R-CBM
IRI-LSF
IRI-LNF
CORE Phonics
STAR Reading
Math CBM
M-Comp
Math-QDM
Math-MNM
Math-NIM
Math-OCM
STAR Math
ISAT ELA
ISAT Math
Speech/ Language
WIDA Access
Overall Student Concerns:
Other Relevant information:
Deficit Skills(Only need to address those skills in which there are concerns)
Basic Reading: (State student concerns)
Core Curriculum
Interventions Provided in the Classroom / Goal: (Given what, who will do what as measured by what by when) / Interventions
(What, Where, How Often, How Long, and by Whom) / Progress Monitoring
(What, How Often, and by Whom)
Reading Fluency:
Core Curriculum
Interventions Provided in the Classroom / Goal: (Given what, who will do what as measured by what by when) / Interventions
(What, Where, How Often, How Long, and by Whom) / Progress Monitoring
(What, How Often, and by Whom)
Reading Comprehension:
Core Curriculum
Interventions Provided in the Classroom / Goal: (Given what, who will do what as measured by what by when) / Interventions
(What, Where, How Often, How Long, and by Whom) / Progress Monitoring
(What, How Often, and by Whom)
Written Expression: (State student concerns)
Core Curriculum
Interventions Provided in the Classroom / Goal: (Given what, who will do what as measured by what by when) / Interventions
(What, Where, How Often, How Long, and by Whom) / Progress Monitoring
(What, How Often, and by Whom)
Math: Calculation: (State student concerns)
Core Curriculum
Interventions Provided in the Classroom / Goal: (Given what, who will do what as measured by what by when) / Interventions
(What, Where, How Often, How Long, and by Whom) / Progress Monitoring
(What, How Often, and by Whom)
Math Problem Solving: (State student concerns)
Core Curriculum
Interventions Provided in the Classroom / Goal: (Given what, who will do what as measured by what by when) / Interventions
(What, Where, How Often, How Long, and by Whom) / Progress Monitoring
(What, How Often, and by Whom)
Oral Expression: (State student concerns)
Core Curriculum
Interventions Provided in the Classroom / Goal: (Given what, who will do what as measured by what by when) / Interventions
(What, Where, How Often, How Long, and by Whom) / Progress Monitoring
(What, How Often, and by Whom)
Visual: (State student concerns)
Interventions Provided in the Classroom / Goal: (Given what, who will do what as measured by what by when) / Interventions
(What, Where, How Often, How Long, and by Whom) / Progress Monitoring
(What, How Often, and by Whom)
Behaviors: (State student concerns)
See attached behavior plan.
Interventions Provided in the Classroom / Goal: (Given what, who will do what as measured by what by when) / Interventions
(What, Where, How Often, How Long, and by Whom) / Progress Monitoring
(What, How Often, and by Whom)
Days absent / Days Tardy / Number of schools attended
CUM file review date / Vision Screening Date and Pass/Fail / Hearing Screening Date and Pass/Fail

Progress monitoring graph with aim line, trend line, decision points, national or local norms and student’s rate of improvement must be attached.

Meeting Date
Team Members
Name / Title/Position

Notes:

Minidoka RTI District Referral/Intervention PlanPage 1 of 5