Tier 1 Rti Form Blank

Euclid City Schools Response to Intervention- Elementary Form (Teacher Log of Interventions) TIER 1 Student Name:

Grade

Teacher Name:

Form Completed

DOB

Check the area(s) of concern: ¨ ¨ ¨ ¨

Reading Comprehension Reading Fluency Reading Skills Other______________

¨ ¨ ¨ ¨

Articulation Listening Comprehension Oral Expression Written Expression

¨ Math Calculation ¨ Math Reasoning ¨ Behavior

Background History (note relevant information, including current assessment data):

Supplemental services and support to be provided: ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨

Small Group Instruction Increased Reading Time Guided Reading Interventions during core instruction/IE period (Description:__________________________________________________) Phonemic Awareness & Phonemic Decoding Sight Word Instruction Supplemental Instruction in Decoding Skills Leveled Literacy (tutor services) Wilson Reading System ® (SPED services) Tutor Services Other:____________________________________________________________

Parent Opportunity for Involvement: ¨ ¨ ¨

Open House Parent Teacher Conference Other:

Statement of Concern (see examples):

Goal: ¨ To reach grade level. ¨ Other:____________________________________________________________

Revision  Date:  September  2013  

Euclid City Schools Response to Intervention- Elementary Form (Teacher Log of Interventions) TIER 1  

Date(s)

Skill Focus

Intervention(s) Used

Group Size

Time and Frequency

Progress Data Results

Revision  Date:  September  2013