RtI STRATEGIES Checklist

Student Name: _____________________________________________ SSN# _______________________ District/Campus_______________________________________DOB ________________Grade_________

Person Requesting RtI Referral ______________________Date Packet Requested: ___________________

Checklist of RtI STRATEGIES

Tier	Process	STRATEGIES Form name and/or Link name	Compl. Date	Completed by (person)	Completed (circle)
TIER 1 – Universal Interventions
1	Universal Screening – Student scores are in the lower 10-20%; Screening done 3 times per year.	Screening List & Sample Screening List-Excel			Yes No
1.1	Parent/Teacher Conference - parents given written copy of notes and intervention plan from Tier I Parent/Teacher conference.	Intervention Plan-Tier 1			Yes No
1.2	Interventions (4 - 6 wks) – teacher uses differentiated instruction, small flexible groups, and CBM to monitor student progress.	RtI Chairperson Log Tier 1 Ideas			Yes No
TIER 2 – Focused Interventions
2	Referral to Tier 2 – classroom observation, health screening (by school nurse) and student info must be filled out before proceeding	Health Screen Student Info/Observ.			Yes No
2.1	Basic Documentation – attendance records, discipline referrals, grades included in RtI packet, student work samples placed in RtI folder				Yes No
2.2	RtI team meeting – develop intervention plan scheduled at least 2-3 times each week for 30 minutes	Intervention Plan-Tier 2 Tier 2 Meeting Script			Yes No
2.3	Interventions (6-12 weeks) –interventionist uses research-based interventions	FCRR Reading Interve… List of RtI Web Res…			Yes No
2.4	Progress Monitoring – curriculum-based measurements (CBM) are used to monitor student’s progress; data is graphed	CBM from interve….. CBM from Dibels			Yes No
TIER 3 – Intensive Interventions
3	RtI team meeting for Referral to Tier 3 –develop intervention plan scheduled daily for 30 minutes in addition to core instruction time	Intervention Plan-Tier 3			Yes No
3.1	Interventions (6-12 weeks) –interventionist uses research-based interventions	FCRR Interv….Tier 3 List of RtI Web Res….			Yes No
3.2	Progress Monitoring – curriculum-based measurements (CBM) are used to monitor student’s progress; data is graphed	CBM from interve…..			Yes No
3.3	Final RtI Team Meeting – student’s progress is determined and student is (1) exited from RtI, (2) given new interventions, or (3) referred to a special program	SE-Referral.pdf 504Referral.pdf			Yes No

Copy in Blue and attach to RtI Folder