Tier 3 Rti Form Blank

Euclid City Schools Response to Intervention- Elementary Form (TIER 3) Student Name:

Grade

DOB

Teacher Name:

Meeting Date

Student Background (to be completed prior to implementation of TIER 3) Does your child have any special interests or hobbies?

Allow parent to express comments/concerns with the team

Describe information about your child in the following areas: Learning: Attention and Concentration: Activity Level: Speech and Language:

Social Skills/Friendships: Please describe any intervention services, including academic, speech and language services, OT and PT (including outside of the school setting).

Please list/describe any and all significant childhood illnesses and medical problems.

Copied and kept in cumulative file. Revision Date: September 2013

Euclid City Schools Response to Intervention- Elementary Form (TIER 3) Please list any current medications (names and dosage):

Other relevant information:

Review and summarize TIER 1 and TIER 2 Data and graphs

Brainstorm TIER 3 Interventions

TIER 3 Intervention Plan

Date:

Goal (write in measurable terms):

Interventions

 

Who Implements?

Date of Initiation and Duration

 

Monitoring Schedule

Copied and kept in cumulative file. Revision Date: September 2013

Euclid City Schools Response to Intervention- Elementary Form (TIER 3)

Summary of Intervention Results (attach all progress monitoring graphs) To be completed by grade level team (must include: teacher, principal, school psychologist, intervention provider/case manager)

Recommendations Met Benchmark, dismiss from progress monitoring Return to TIER 2 with monthly strategic monitoring Continue TIER 3 with weekly progress monitoring Refer for Multifactored Evaluation (summary and graphs must be attached) Signatures Team Signatures

 

Title

Date

 

Copied and kept in cumulative file. Revision Date: September 2013