Secondary Student Response To Intervention (Rti) Plan Form
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1Student Name _________________________ID____________DOB ______Teacher ________________Grade ___School______________
LEP Y __N __Denial Y __N__ Language of Instruction ___________Special Education Y __N __Dyslexia Y__ N ___Date_____________
SECONDARY STUDENT
RESPONSE TO INTERVENTION (RtI) PLAN
This form is completed and updated by classroom teacher in conjunction with professionals.
Indicate student’s behavioral/other major area(s) of difficulty. [Need documentation to support]
____ Task Completion
____ Constant Breaking of Rules
____ Level of Anxiety
____ Level of Distractibility
____ Argumentativeness
____ Low Energy Level
____ Short Attention Span
____ Frequent Temper Outbursts
____ Sadness, Tearfulness
____ High Activity Level
____ Fighting
____ Social Withdrawal
____ Acting Before Thinking
____ Avoids Responsibility
____ Poor Concentration
____ Poor Organization and Work Habits
____ Confusion
____ Demanding Constant Attention
Indicate student’s major academic area(s) of difficulty. [Need documentation to support.]
____ Oral Expression
____Oral Reading (Word Recognition)
____Math Calculation
____ Articulation
____Spelling
____Math Reasoning
____ Phonics
____Handwriting
____Understanding Concepts
____ Listening Comprehension
____Written Language
____Retention of Learned Materials (Poor test grades)
____ Vocabulary
____Following Oral Directions
____Rate of Performance in Comparison to Peers
____ Decoding
____Following Written Directions
____ Reading Comprehension
____Remembering Details
This information is a record of strategies tried in response to student’s difficulties listed above. Teacher documents/initials response.
TIER I
# of
Progress/
Teacher
Weeks
No
Behavior
Initials/
Tried
Progress
Date
(15-18)
(P/NP)
(Successful with 80-85% of students)
BEHAVIOR/MEDICAL
(Required for ALL Students)
1. Student’s medical history has been reviewed.
2. Hearing and vision have been checked -complete RtI Health Information form.
3
.
Medical reports have been received and reviewed with appropriate staff.
(NOTE: FOR SECTION 504, REVIEW MEDICAL AND MOVE TO STATUS LOG.)
CLASSROOM ENVIRONMENT (REQUIRED)
(Required for ALL Students)
1. Classroom rules are posted and taught/reviewed every two weeks.
2. Classroom has regular routines and procedures that are clear, taught and practiced 1x 2 wks min.
3. Behavior management system is clearly displayed and has been taught to all students.
4.
Appropriate rate of positive interactions/non-contingent attention (3 positive to 1 negative).
5
Attendance issues have been addressed.
.
POSITIVE BEHAVIORAL SUPPORTS (REQUIRED)
(Required for Behavioral Referrals)
1. Rate of praise for appropriate behavior (3 positive to 1 negative).
2. Private talks
3. Non-verbal cues
4. Proximity control
5. Opportunities to regain composure
6. Behavior/Academic contracts
7. Classroom jobs-rotated and assigned evenly (if appropriate)
8. Opportunities to re-do assignments for credit
9. Parent conference(s) and/or positive contact (notes) to parent-first contact is positive.
10. Referral to Counselor
11. BSP/LSSP consultation and implementation of strategies for classroom management.
SAISD C&I Department-RtI 1-Secondary
1 of 12
REVISED: 09/2009
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