Lonsdale PIT Team Referral 2020-21
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Email *
Student Name: *
Grade: *
Homeroom Teacher: *
Referring Staff: *
Reason for Referral *
Required
Describe your specific concerns prompting this referral. *
Please complete the rest of the sections below for Academic Concern referrals. Is the student already in RTI2 Intervention?
If already in a Reading RTI2 Intervention, indicate the Tier and Area of Concern
Oral Reading Fluence
Comprehension
Tier 2
Tier 3
Clear selection
If already in a Math RTI2 Intervention, indicate the Tier and Area of Concern
Fact Fluency
Math Concepts and Application
Tier 2
Tier 3
Clear selection
Does the student receive ELL services
Clear selection
If the student is in ELL, provide the following proficiency levels indicated by their last WIDA assessment. WIDA Listening proficiency is:
WIDA Speaking proficiency is:
WIDA Reading proficiency is:
WIDA Writing proficiency is:
WIDA Comprehension proficiency is:
Time you teach Reading Whole Group *
Student's Reading Small Group Time *
Time you teach Math *
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