Initial Request for RTI Revised

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this form to the best of your ability. The information is crucial in creating a hologram of the student in order that the RTI team can provide effective intervention support.

Student *

Use classroom number and the last four digits of NYC ID # (e.g. a student in room # 425 with NYC ID # 123456789 would be 425-6789) DO NOT USE STUDENT'S NAME

Requested by *

Is child an ELL (English Language Learner)? *

Yes

Child received ESL in the past. Passed NYSESLAT

Has student ever been held over? If "yes", in what grade? *

Areas of Concern *

Check all that apply. Some of the choices refer you to checklists. all of these checklists are posted on the PS 23 website in the RTI section. Please use them to help guide your descriptions in each of the areas you have checked.

Reading (Use TC assessments. In addition to the independent reading level, please include the # of known sight words, include the mastered level, spelling, concepts of print level and running record)

Writing (Use TC writing continuum, descriptors to guide discussion and student checklists)

Speech and Language (please refer to checklists under Speech and Language Therapy Forms)

Occupational Therapy (please refer to checklists under Occupational Therapy Forms)

Physical Therapy (please refer to checklists under Physical Therapy Forms)

Health (General health e.g. frequent/chronic colds/coughs, asthma, allergies etc., vision and hearing issues, hygiene)

Attendance (Please check here if chronically late or absent or attendance patterns are of any concern at all. If this is the case you should have already reported this to Attendance Dept.)

Other:

Required

Details: Reading *

Please use TC assessments, in-book assessments and observations to complete this section. In addition to the independent reading level, please include the # of known sight words , e.g. 35/200, include the highest level mastered on a particular list, e.g. List A 20/25. Please include letter knowledge, letter identification, concepts of print, reading comprehension (literal, Inferential, fluency and oral reading rate [beginning with level J]) and observable reading behaviors observed in the running record and during conferences (strategies used, strategies neglected, what sources of info child is relying on)

Details: Writing *

Copy and make available writing rubric and writing sample for the team. Describe any observable behaviors associated with writing. If you have a current progress report that is applicable you can copy and paste what you have already written. If the student is on or above grade level just list Writing Rubric Level and state whether student is "ON' or "Above" grade expectations at this time.

Current IEP/ AIS/ At-Risk Services *

Please list any services this student receives during the school day (Reading, ESL SETSS, Math, Speech, Counseling, OT, PT etc.) List the provider and the frequency of the service. If "none" please indicate so.

What strategies have you already tried? *

If you have already used strategies or techniques please list them and whether or not they helped. This includes pre-intervention strategies/activities supplied by an OT or Speech Therapist.

Has there been any parent outreach regarding this issue? If "yes" what was the outcome? *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms