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GHS Student RtI Information Sheet
Please complete the following information for each student involved in the RtI process this cycle.
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* Indicates required question
Teacher Last Name
*
Your answer
Role
*
Choose
Teacher
Counselor
Administrator
Student First Name
*
Your answer
Student Last Name
*
Your answer
ID#
*
Your answer
Grade Level
*
Your answer
Course Description
*
Your answer
Define the Problem
*
What is your main concern regarding the student? How long has the student demonstrated this concern? List the subjects the student has failed.
The student has poor attendance
The student is frequently distracted and off task
The student has low scores on quizzes/tests
The student is often sleeping in class
The student is often on or distracted by personal technology (phone, iPad, etc.)
The student spends to much time socializing with peers
The student fails to complete/hand in assignments
The content is too difficult for the student
These concerns are new
These concerns have been on going
Other:
Required
Analyze the Problem
*
What data are you using? When and where is the concern being seen? What area of improvement would you like to target?
Skyward- Attendance
Skyward- Grades
Observation
Tutorial Logs
Student Conference (input from student)
Other:
Required
Current Intervention(s)
*
What interventions have you tried and what was the result? What specific outcomes would you hope to see from the interventions?
Preferential seating
Teacher proximity
Redirection of attention
Frequent student check-ins
Small group instruction or stations
Group/collaborative work
Conference with student
Tutorials
Parent contact
Extended time
Reteach and retest opportunities
Test corrections
Modify assignments
Differentiate or chunking assignments
Organizational strategies/apps
Provide notes/modify notes
Positive reinforcement
Student attendance contract
Home visit by admin
Behavior Plan
Other:
Required
Desired Academic Goal
*
State a measurable, short term goal for the student.
Attend class at least 90% of the time
Complete assignments in a timely manner
Attend tutorials weekly
Complete Cycle Recovery
Stay on task for at least 70% of the class
Earn a Cycle grade of 70% or higher
Other:
Required
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