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1 2013–2016 RESPONSE TO INTERVENTION ACADEMIC INTERVENTION SERVICES PLAN INTRODUCTION Academic Intervention Services (AIS) are intended to supplement instruction provided by the general education teacher and assist students in meeting the New York State (NYS) Common Core Standards. This additional support is provided by utilizing a variety of strategies. Interventions are intended to assist students who are at risk of not achieving the NYS Common Core Standards in English Language Arts (ELA), Mathematics, and/or Science, or who are identified as not meeting designated performance levels, or who have mitigating circumstances preventing achievement. Interventions shall be made available to students with disabilities on the same basis as non-disabled students, and shall be consistent with a student’s individualized education program. An effective Response to Intervention (RTI) program consistent with section 100.2(ii) of the Regulations of the Commissioner includes the following: appropriate instruction delivered to all students in the general education class by qualified personnel; appropriate instruction in reading shall mean scientific, research-based reading programs that include explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency (including oral reading skills), and reading comprehensive strategies; screenings applied to all students in the class to identify those students who are not making academic progress at expected rates; instruction matched to student need with increasingly intensive levels of targeted intervention and instruction for students who do not make satisfactory progress in their levels of performance and/or in their rate of learning to meet age or grade-level standards; repeated assessments of student achievement, which should include curriculum measures to determine if interventions are resulting in student progress toward age or grade-level standards; in K–8 AIS, AIMSweb may be used, in 9–12, teacher-made assessments may be used; the application of information about the student’s response to intervention to make educational decisions about changes in goals, instruction, and/or services and the decision to make a referral for special education programs and/or services; and written notification to the parents when the student requires an intervention beyond that provided to all students in the general education classrooms that provides information about:

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2013–2016 RESPONSE TO INTERVENTION

ACADEMIC INTERVENTION SERVICES PLAN

INTRODUCTION Academic Intervention Services (AIS) are intended to supplement instruction provided by the general education teacher and assist students in meeting the New York State (NYS) Common Core Standards. This additional support is provided by utilizing a variety of strategies. Interventions are intended to assist students who are at risk of not achieving the NYS Common Core Standards in English Language Arts (ELA), Mathematics, and/or Science, or who are identified as not meeting designated performance levels, or who have mitigating circumstances preventing achievement. Interventions shall be made available to students with disabilities on the same basis as non-disabled students, and shall be consistent with a student’s individualized education program. An effective Response to Intervention (RTI) program consistent with section 100.2(ii) of the Regulations of the Commissioner includes the following:

• appropriate instruction delivered to all students in the general education class by qualified personnel;

• appropriate instruction in reading shall mean scientific, research-based reading programs that include explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency (including oral reading skills), and reading comprehensive strategies;

• screenings applied to all students in the class to identify those students who are not making academic progress at expected rates;

• instruction matched to student need with increasingly intensive levels of targeted intervention and instruction for students who do not make satisfactory progress in their levels of performance and/or in their rate of learning to meet age or grade-level standards;

• repeated assessments of student achievement, which should include curriculum measures to determine if interventions are resulting in student progress toward age or grade-level standards; in K–8 AIS, AIMSweb may be used, in 9–12, teacher-made assessments may be used;

• the application of information about the student’s response to intervention to make educational decisions about changes in goals, instruction, and/or services and the decision to make a referral for special education programs and/or services; and

• written notification to the parents when the student requires an intervention beyond that provided to all students in the general education classrooms that provides information about:

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o the amount and nature of student performance data that will be collected and the general education services that will be provided;

o strategies for increasing the student’s rate of learning; and o the parents’ right to request an evaluation for special education

programs and/or services.

• The school district has defined the specific structure and components of the RTI program, including, but not limited to, the criteria for determining the levels of intervention to be provided to students, the types of interventions, the amount and nature of student performance data to be collected, and the manner and frequency for progress monitoring.

• The school district ensures that staff has the knowledge and skills necessary

to implement an RTI program. The Spackenkill Union Free School District provides an RTI program that aligns with the Commissioner’s Regulations. Our program includes classroom teachers, special area teachers, AIS teachers, Special Education teachers, as well as School Psychologists, Social Workers, ESL, Speech, OT, PT, Nurse, and School Counselors, for addressing students’ needs in areas that can affect academic achievement, including, but not limited to, academic deficiencies. Decisions related to fluency, intensity, duration, and method of service are based upon individual student needs. It is expected that administrators, classroom teachers, support personnel, and parents will work in collaboration through RTI process in making appropriate educational decisions for all students. All students are eligible for RTI review and services, including those with disabilities and/or limited English proficiency if they fail to meet the designed state performance standards or district-approved benchmarks. Additionally, Limited English Proficient (LEP) / English Language Learner (ELL) students who do not achieve the annual designated performance standards as stipulated in CR Part 154 are eligible for AIS. Students who demonstrate specific areas of weakness on the NWEA Measures of Academic Progress (MAP) testing will be considered for placement in the program. SECTION I: DESCRIPTION The plan is intended to describe services for students in the district in grades K–12. The district reviews individual building needs each year by disaggregating data on:

• needs analysis of student performance; • the number of students receiving AIS at each grade level and within each

standards area; • the range of performance levels of eligible students as determined through

state assessments and district-approved criteria; and

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• staffing implications, instructional approaches, and scheduling options needed to meet the range of intensity and services required by the interventions.

The RTI teams, Principals, and Assistant Superintendent for Curriculum, Instruction, and Pupil Personnel Services conduct ongoing oversight, monitoring, and review. Each building has a regularly scheduled RTI meeting in which a multidisciplinary team evaluates students recommended for consideration of interventions. The data is stored in a product called RTIm and maintained by both the RTI team and the case manager assigned to the students. Research-based, scientifically validated interventions are recommended for use with the student. AIMSweb is used to progress monitor all students receiving intervention services. All decisions are made based on actual data obtained from the student’s progress. A three-tiered RTI program is in place to allow for flexibility in meeting the needs of students with varying levels of deficiency with:

• Tier 1 interventions available in all settings for all students with the aim of being preventive and proactive.

• Tier 2 interventions designed for small groups of students with an expectation of high efficiency and rapid response and are provided by an AIS instructor in either a pull-out or push-in model as determined by the team.

• Tier 3 interventions generally for students who require the highest degree of frequency and lowest number of students.

The district believes the single most important factor for student success is direct classroom instruction. However, students who struggle should be afforded appropriate and targeted opportunities for academic assistance and intervention, based on data analysis (“root cause analysis”) of multiple measures so that they may be successful in meeting the New York State Common Core Standards. Academic Intervention is described as:

• targeted, intensive, differentiated instruction either within the general education classroom and/or including small group instruction, individualized instruction, and lower student/teacher ratio;

• student support services needed to address barriers to improved academic performance, such as monitoring, counseling, etc.

We offer specific AIS in English Language Arts and Mathematics in grades K–12, and additionally in science grades 5-12. Other interventions may be provided as indicated by the Social Workers, Psychologists, OT, PT, Speech, Nurses, and Guidance Counselors.

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The current model utilizes appropriately certified professionals for intervention. Teacher certification may be generalized (K–6, special education), or specific to the intervention area (reading, language, math, science, and/or social studies). Certified teachers provide services for grades K–12. New York State–certified reading teachers coordinate programs and provide instruction to students at risk in reading and writing, grades K–8. SECTION II: PROCESS USED TO DETERMINE AIS NEED – CRITERIA

FOR ELIGIBILITY

1. All students placed in academic intervention must go through the RTI

process or have scored below a 3 on one or more state exam. The forms provided in the Appendix of this document are REQUIRED to be filled out at or in advance of the initial meeting, during the intervention process, and at the review meetings.

2. Students in grades K–8 will be considered for Tier 2 AIS if:

• They score below Designated Performance Level (below a 3) on

Elementary or Intermediate state assessments in ELA, Mathematics, Science.

• Their score on the STIR, DRA, NWEA MAP, or other formative assessment indicates poor progress.

• They are recommended by the RTI team. 3. Students in grades 9–12 will be considered for Tier 2 AIS if:

• They score below a 3 in ELA or Mathematics on the 8th grade NYS

Assessment. • They score below the approved passing grade on any Regents exam

required for graduation in ELA, Mathematics, Science, or Social Studies.

• They are recommended by the RTI team. • Scores received on the NWEA MAP testing. • 9th graders may be recommended by the Middle School team.

4. In grades where no assessments are given (K–2 and some 6–12), students may be considered for services by the RTI team if they are determined to be at risk of not meeting standards according to criteria established by the district. The district procedures will always be used when a student is absent for all or part of a state assessment, or when a student transfer from out of state or the country. Teachers must bring a student to RTI to discuss what

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Tier 1 and/or Tier 2 interventions are appropriate.

5. The RTI team will use the following research-based criteria in determining eligibility for AIS services and must bring evidence of interventions that have been tried and have failed to make a difference:

• Diagnostic Assessments • Early Reading/Literacy Assessments • Subject Skill, Concept, Knowledge Assessments • Assessment Portfolios • Curriculum-Based Measures • Formative Assessments • Standardized Norm-Referenced Tests (above grade 3) • Standardized Criterion-Referenced Tests • Regents Exams • Detailed Progress Monitoring of multiple interventions attempted • Other valid, reliable assessments

And will include a Review of Classroom Performance with evidence of:

• Participation, class work, homework • Report Card Grades • Student performances/demonstrations • Student records (attendance, discipline, etc.) • Teacher input regarding student needs • Progress monitoring

SECTION III: MEASUREMENT TOOLS State-Mandated Testing Current New York State–mandated tests include Regents Exams, Regents Competency Tests (RCT), if applicable, ELA testing for grades 3–8, Mathematics testing for grades 3-8, and Science in grades 4 and 8. Every student scoring at Level 1 or 2 on the ELA / Mathematics / Science must receive academic intervention. However, the intensity of these services may vary. Students in the upper range of Level 2 might not need additional instruction. However, they must receive some form of AIS. Monitoring of a student’s performance by school staff would be an appropriate student support service. This could include such activities as regular progress checks, further assessments, and meetings with the classroom teacher to adjust instruction, if necessary.

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Monitoring Progress and Academic Re-testing AIS services must be provided for at least one semester. A student may be discharged after one semester of intervention is a “passing” score on an internal standardized test is achieved or other testing, report card grades, and teacher recommendations are used to discharge students who no longer demonstrate a need for services because they have made adequate progress toward their goal. Students receiving intervention services may take a local assessment to “test out.” AIMSweb is used for measuring, monitoring, and recording progress. Internal District Testing In addition to AIMSweb progress reporting, Spackenkill Union Free School District will use the following procedures, tests, and criteria to determine eligibility for services and discontinuation of services:

• Kindergarten screening (May of pre-school year prior to entrance to Kindergarten)

• Local standardized assessments (NWEA MAP)

Literacy Testing

• STIR testing (grades K–1) (20th percentile or below) • DRA testing (June of K and grades 1–5) • Other criterion-referenced testing, such as QRI, IRI, running records,

etc. Mathematics Testing

• Mathematics Inventory (grades 2–3) SECTION IV: COMPONENTS OF RTI-AIS ENTRANCE CRITERIA

• If a review of data indicates that a student is at risk of not meeting state learning standards, the student is considered to need interventions.

• If Tier 1 intervention strategies have been exhausted and evidence of adequate progress monitoring of research-based interventions is presented.

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Progress Monitoring Includes:

• Identify the student problem and set a goal. • Decide on a data collection method after selecting the interventions. • Collect data to calculate baseline. • Determine the time span of each intervention. • Decide how student progress is to be measured and reported. • Evaluate the intervention outcome.

Strategies for Additional Instruction

• Extra time for focused instruction • Staffing/scheduling to increase student-teacher instructional contact

time • Differentiated instructional methods

Student Support Services

• Guidance • Counseling • Study Skills • Attendance Monitoring • Behavior Monitoring • Health/Wellness Counseling and Monitoring • Referral for community agency support as eligible • Limited English Proficiency (LEP)/England Language Learner (ELL)

services EXIT CRITERIA

• If a review of data indicates a student has met state learning standards the student no longer needs AIS if continued progress is made.

• If actual student progress meets or exceeds the goal, the intervention is judged to be successful.

Possible Range of Academic Intervention

• Scheduling options including additional class time (extended courses) • Co-teaching (blended classrooms) • Individualized Instruction

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• Small Group Instruction • Computer-Assisted Instruction • Reduced student-to-teacher ratio • Before-school, after-school, or summer programs (parental approval) • Alternative Education Placement

RTI Services May Include Referral for the Following in Addition to the Academic Referral:

• Attendance concerns • Discipline concerns • Family-related issues • Social/emotional issues • Health-related issues • Mobility/transfer issues

When indicated, students in grades K–12 may be referred to one or more outside agencies for additional support and/or assistance. RTI SERVICES INCLUDE: At the High School:

• ELA, Mathematics, Science, and Social Studies AIS sessions (9-12) • Co-taught English 9, 10, 11 • Co-taught Global Studies and American History • Targeted Earth Science and Biology for students at risk of not

demonstrating proficiency on the Regents exams • Guidance Counseling, Psychological Services, Social Worker, ESL • Study Skills class • After School Academic Study Hall

At the Middle School:

• Study Skills mentoring—grades 6–8. Proper use of assignment book, test taking skills, note taking, and a variety of other techniques are taught and reinforced.

• Co-taught English, Mathematics, Science, and Social Studies (grades 6–8)

• AIS ELA and AIS Mathematics • Guidance Counseling, Psychological Services, Social Worker, ESL,

Speech and Language Services

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At the Elementary Level:

• Elementary AIS ELA • Mathematics AIS for students in grades 4 and 5 who did not receive a

3 or 4 on the state assessment in Mathematics, and who meet the district criteria for this service

• Elementary Intervention Specialist to work with RTI teams to consult and problem solve around students’ learning and behavioral needs

• Intense specialized reading instruction intervention for students in Kindergarten and beyond who continue to have difficulties in the areas of phonemic awareness, phonics, fluency, vocabulary, and comprehension

• Speech and language improvement to children with weak articulation skills in early elementary grades

• Speech and language consult to regular education teachers to support literacy instruction

• Group and individualized counseling SECTION V: PLAN FOR PARENT CONTACT AND INVOLVEMENT PROCEDURES FOR PARENT NOTIFICATION The building principal (or designee) will be responsible for parental notification indicating a need for AIS. This notification will be made in writing and will include a summary of services being provided to the student, including when the services will be provided. The reason(s) for intervention will be reviewed, and the consequences of not achieving the standards will be stated. Parents will also be kept apprised of their child’s progress through quarterly written reports, parent conferences, and/or consultations, and, when appropriate, will be given suggestions for working with the student at home. The teacher or support staff person providing intervention services to the student will be responsible for the above-required communications with parents. When services are discontinued, the parent will be notified in writing that the services will be ending, and the criteria for ending services. SECTION VI: PROVISION FOR MANAGEMENT AND COORDINATION OF SERVICES (record keeping, timelines, roles and responsibilities, monitoring, etc.)

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RTImDirect, a web-based software program, is used to document intervention services and progress. A student receiving intervention will also have a folder for each area of service. A folder may contain standardized test scores, state-mandated test scores, diagnostic materials, and samples of work. Parent communication, including a notification letter, progress monitoring (such as running records, benchmarks, informal test results, criterion-referenced testing), and periodic reports are included in the folder. Results of standardized testing are reported to parents/students, teachers, and to building principals. Student progress is documented in a variety of ways: report cards, follow-up RTI meetings, annual standardized testing, observations, and parent/teacher conferences. When a student enters and exits any intervention program, a form is required and is signed by the building principal. DATA ANALYSIS The RTI teams review student data from state and local assessment instruments regularly. Current and longitudinal data are also analyzed to determine academic needs and inform instruction. PROCESS AND TIMELINE Intervention Services may start any time and should continue to allow for enough data to be collected to clearly demonstrate whether that intervention was successful (i.e., at least 6 instructional weeks). For example:

• A classroom teacher remediates a student for oral reading fluency. After 6 weeks of progress monitoring the classroom teacher determines if the intervention was successful. If it was not, another intervention is put in place and monitored for an additional 6 weeks.

• After classroom interventions have been exhausted, the classroom teacher may schedule a meeting with the RTI team and bring all evidence of progress monitoring for consideration of Tier 2 interventions.

• Should Tier 2 interventions occur, progress monitoring continues and evidence of progress is reviewed in the RTI meeting on a 6-week basis.

• After all Tier 2 interventions have been exhausted, the RTI team may consult with the Assistant Superintendent for Curriculum, Instruction, and Pupil Personnel Services for consideration of Tier 3 interventions or classification. At that meeting all evidence of progress monitoring is mandated to be presented.

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SECTION VII: REVIEW COMMITTEE_______________________________________

The members who served on the committee to review the Response to Intervention & Academic Intervention Services Plan in October 2013 were:

Joann Klein, Joann Shaffer, Tracie Phillips, Katherine Casucci, Peggy Pisano, Tolomeo, Mary Camburn, Rebecca Chaoussoglou, Adam Hammond, Diana Babington, Kathleen DeFreest, John Farrell, Tina DeSa, Michael Murphy, Steve Malkischer

References

Burns, M.K., & Gibbon, K. A. (2008). Implementing response-to-intervention in elementary and secondary schools. Routledge: New York.

Witt, J.C., and VanDerHeyden, A.M., & Gilbertson, D. (2004). Troubleshooting behavioral interventions. A systematic process for finding and eliminating problems. School Psychology Review, 33, 363–383.

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APPENDIX

Matching the Intervention to the Student Problem

Student Name:______________________ Grade Level: ____________ Service Provide Name:________________ Subject (if applicable): ______________ Date:_______________

Identify the Problem

Conditions: Environmental Conditions or Task Demands ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Describe Observable Academic Behavior ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ Typical or Expected Level of Performance ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________

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Student Name:______________________ Grade Level: ____________

Service Provide Name:________________ Subject (if applicable): ______________ Date:_______________

Where is the Skill Deficit (check all that apply)

Motivation Determine if student motivation plays a main or supporting role in academic underperformance. Describe strategies to engage the student. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Acquisition (Student needs to improve accuracy) Fluency (Student needs to increase pace) Generalization (Difficulty distinguishing between target skill & similar skills) Adaptation (Student has difficulty adapting existing skill to fit novel task)

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Intervention Script Builder

Student Name:______________________ Grade Level: ____________ Service Provide Name:________________ Subject (if applicable): ______________ Date:_______________

Preparation Steps

This Step Took Place

1. Teacher Responsibility • Teacher understands

responsibility to implement the intervention

YES ___________ NO ____________

2. Teacher Acceptability • Teacher states intervention is

feasible and acceptable for the identified student problem

YES ___________ NO ____________

3. Baseline Data/Information • Present Level of Performance

(documentation provided)

YES ___________ NO ____________

4. Teacher Intervention Training • Teacher requires training to

carry out the intervention

YES ___________ NO ____________

5. Additional Resources Needed to Provide Intervention

YES ___________ If so, what? _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ NO ____________

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Academic Interventions Critical Component Checklist Student Name:______________________ Grade Level: ____________ Service Provide Name:________________ Subject (if applicable): ______________ Date:_______________

Time Allotted

Student/Teacher Ratio (Check which applies)

Length of Intervention • Minutes

_______________

Frequency • Times per week

_______________

Duration • # of weeks

_______________

• Large Group (more than 10 students)

__________

• Small Group (less than 10 students)

__________

• Individualized

__________

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Intervention Steps This Step Took Place 1. ______________________________ ________________________________ ________________________________ ________________________________

YES ___________ NO ____________

2.______________________________ ________________________________ ________________________________ ________________________________

YES ___________ NO ____________

3.______________________________ ________________________________ ________________________________ ________________________________

YES ___________ NO ____________

4.______________________________ ________________________________ ________________________________ ________________________________

YES ___________ NO ____________

5. ______________________________ ________________________________ ________________________________ ________________________________

YES ___________ NO ____________

6. ______________________________ ________________________________ ________________________________ ________________________________

YES ___________ NO ____________

7.______________________________ ________________________________ ________________________________ ________________________________

YES ___________ NO ____________

Student Name:______________________ Grade Level: ____________ Service Provide Name:________________ Subject (if applicable): ______________ Date:_______________

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Progress Monitoring

Documenting the Intervention and Collecting Data Student Name:______________________ Grade Level: ____________ Service Provide Name:________________ Subject (if applicable): ______________ Date:_______________

Goal

Interventions 1. 2. 3.

How Measured 1. 2. 3.

Location

Frequency 1. 2. 3.

Day/Week= Min/Day=

Was the student present?

Number of intervention sessions present/total possible

To what degree were you able to carry out the intervention?

Not at all 1 Somewhat 2 Fully 3

Check in date

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Tracking Intervention Effectiveness

1. Explicit Instruction (describe intervention) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. Active engagement in activity/lesson ______YES ______NO Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. Work product is accurate ______YES ______NO Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 4. Performance Feedback (student informed of progress status) ______YES ______NO Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 5. Accommodations Do they alter academic expectations? ______YES ______NO Comment:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________

Student Name:______________________ Grade Level: ____________ Service Provide Name:________________ Subject (if applicable): ______________ Date:_______________

Student Name:______________________ Grade Level: ____________ Service Provide Name:________________ Subject (if applicable): ______________ Date:_______________

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Evaluating Non-Responders to Intervention

Review of Tier 1 Interventions (within classroom for a period of 4–8 instructional weeks) (Teacher developed)

Student participation: (#present) __________ (#possible) (Review of Tier 2 Interventions (small group 6–8 instructional weeks) (3 separate intervention trials) (AIMSweb) (NWEA MAP) Review of Tier 3 Interventions (smaller group size and/or individual and increased duration per week) (AIMSweb) (NWEA MAP) Additional comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Review Academic Data Please check & attach the following: Work samples/classroom performance NWEA MAP results AIMSweb results Student participation: (#present) __________ (#possible) Define discrepancy from peers (at least one standard deviation below mean. Mean provided by RTI team) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Non-Responders to Tier Student Name:______________________ Grade Level: ____________ Service Provide Name:________________ Subject (if applicable): ______________ Date:_______________ Tier 1: Successful attempts # attempts ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Tier 2 & 3: Review student’s Individual Progress Slope (based on at least 3 data points) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________

Non-Responder Status

Determining Non-Responder Status Student’s Individual Progress Slope remains at least one standard deviation below the mean after Tier Intervention Trials ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Additional comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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RTI Referral Form

Student Name:______________________ Grade Level: ____________ Service Provide Name:________________ Subject (if applicable): ______________ Period and/or days course meets:_______________ Date:______________________ Reason for referral:______________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Attendance: Please fill in the number of days the student has been absent from your class period in the marking period

Please provide an approximate average for each section you use for grading.

Test: Class work:

Quizzes: Projects:

Homework: Other (please specify):

Have you noticed any patterns with the student’s performance? Briefly explain. ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ Strengths: Describe student’s primary strengths. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Concerns: Describe the primary concerns you have about this student. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

# Days

Absent/Tardy/ Early Exit

(nurse, lessons, others)

Divided

By

Elapsed School Days in

Marking Period

Equals

Absence

rate

Times

100

Absence rate (percentage)

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What current interventions are being provided to the student? __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________