Response to Intervention

Tier 2 Intervention Worksheet

Date Completed
School
Problem Identification: What is the problem behavior (i.e. fluency, comprehension, number sense, defiance, disrepect)? Problem Analysis: Why is the problem occurring? State hypothesis.
What was the range of scores for these students? What is the acceptable level of performance (cut-off score)? This is the
discrepancy statement for the problem behavior.

Goal: After _____ sessions, how much growth would be appropriate in the identified problem? State behavior in observable and measurable terms. Include length of time, the behavior, the condition in which
the behavior will occur, and the criterion for success.

Intervention
# of Minutes
per Session

Interventionist

No Change
Discrepancy
Remained the
Same

Recycle through
P.S. Process

Regression
Discrepancy
Increased

Person Completing Progress Monitoring

(Mark one)

Discontinue
Intervention

Improvement
Discrepancy
Decreased

Frequency of Progress
Monitoring

Data Decision for

this Intervention

Result of Intervention
(Mark one) Based on the aimline and
trendline of graphs:

Student
(alphabetical, last name first)

Progress Monitoring Tool

Intensify
Intervention

# of Sessions
per Week

Continue
Intervention

End Date

Modify
Intervention

Start Date

Fade
Intervention

Description of Intervention

Progress Monitoring

Effectiveness of Intervention

# of students in this intervention

________

# of students decreased discrepancy

________

Divide the number of students who decreased discrepancy by the number of students
in this intervention. This is the percent of children who showed success in the
intervention. This is the Intervention Effectiveness.

Students who showed success

_______%

* As a general rule, if this number is below 70%, the intervention has not been
effective. When interventions are not effective, all students should remain in this Tier
intervention without intensification. The team should complete a new form, revisit the
problem solving cycle, and change the intervention.

Response to Intervention
Tier 3 Intervention Worksheet
Date

Next Meeting Date

Student

Grade

Teacher

Case Coordinator

Problem Identification: What is the problem behavior (i.e. fluency, comprehension,

number sense, defiance, disrepect)? Describe the student's data trend on this
problem area through Tier 2 interventions received.

Problem Analysis: Why is the problem occurring? State hypothesis.

Goal: After _____ sessions, how much growth would be appropriate in the identified problem? State behavior in observable and measurable terms. Include length of time, the
behavior, the condition in which the behavior will occur, and the criterion for success.

INTERVENTIONS
TIER 1 Support: Please list the accomodations and modifications that will be provided during Tier 1 to allow the student exposure and accessibility to Core Instruction (i.e.
shortened assignments, modified grading, tests read, precorrection).

TIER 2 Intervention(s): Please list the Tier 2 Intervention(s) the student will continue receiving.
Description of the Intervention

Start Date

End Date

# of Sessions
per Week

# of Minutes per
Session

Interventionist

# of Minutes per
Session

Interventionist

TIER 3 Intervention(s): What additional interventions will support this student on the identified problem and hypothesis?
Description of the Intervention

Start Date

End Date

# of Sessions
per Week

PROGRESS MONITORING
Progress Monitoring Tool

Frequency of Progress Monitoring

Result of Intervention
(Mark one) Based on the aimline and
trendline of graphs:
Discrepancy Decreased

Discrepancy Increased

Discrepancy Remained the

Same

Person Completing Progress Monitoring

Data Decision for this Intervention

(Mark one)
Discontinue
Intervention

Fade
Intervention

Modify
Intervention

Continue
Intervention

Review Problem
Solving Cycle

Seek Entitlement

Response to Intervention
Individual Student Intervention Integrity Documentation Form
Tier 2 and Tier 3

Student:

Teacher:

School:

Grade:

Please document each intervention and the dates provided. Intervention(s) must be implemented consistently with supporting data attached.
Use multiple copies of this page, if needed.

Tier

Goal

Intervention Description

Start Date

End Date

# of Sessions per
Week

# of Minutes per
Session

Interventionist

Progress
Monitoring Tool

Frequency of Progress
Monitoring

Person Completing
Progress Monitoring

# of Minutes per
Session

Interventionist

Progress
Monitoring Tool

Frequency of Progress
Monitoring

Person Completing
Progress Monitoring

Dates Student
Received
Intervention:

Result of Intervention
(Mark one) Based on the aimline and
trendline of graphs:
Discrepancy
Decreased

Discrepancy
Remained the
Same

Discrepancy
Increased

Tier

Goal

Data Decision for this Intervention

(Mark one)
Discontinue
Intervention

Fade Intervention

Modify
Intervention

Continue
Intervention

Intensify
Intervention

Review Problem
Solving Cycle

Intervention Description

Start Date

End Date

Notes:

# of Sessions per
Week

Dates Student
Received
Intervention:

Result of Intervention
(Mark one) Based on the aimline and
trendline of graphs:
Discrepancy
Decreased

Discrepancy
Increased

Discrepancy
Remained the
Same

Data Decision for this Intervention

(Mark one)
Discontinue
Intervention

Fade
Intervention

Modify
Intervention

Continue
Intervention

Intensity
Intervention

Review Problem
Solving Cycle

Notes:

Problem-Solving Information
Peoria Public School District #150
(Complete this form prior to the Tier 3 Problem Solving meeting)
Student

Birthdate

Teacher

Grade

Gender

Parent/Guardian
Phone #

Home

Work

Cell

Email

Best Way to Contact

Student Resides With

Relationship

Address
BACKGROUND INFORMATION:
Student's Primary Language
Retention ()

Parent's Primary Language _____________________________

Yes

No

Previous Evaluation

If yes, what grade?

Speech/Language

Agency Performing Evaluation/Providing Services

Special Education

Outside Evaluation

___________________________________________________________________________________________

Special Services

Speech

OT

PT

504

Other

Vision Screening

Pass

Fail

Date

Glasses

Yes

Hearing Screening

Pass

Fail

Date

Attendance

Days Absent

No

Days Tardy

Health Concerns
Current Medications
ASSESSMENT DATA:
Attach all data from Previous interventions.
STUDENT STRENGTHS/INTERESTS:

CURRENT LEVEL OF PERFORMANCE:

State in observable, measurable terms. When does this occur? How often? What preceded the event?

EXPECTED OUTCOMES:
What would you like the student to be doing better or differently?

COMMENTS:

Date Parent Contacted

Signature of
Referring Person

Date

Approved by Principal

Date

CSSSForms 9/08

Problem Solving Meeting

Sign In Sheet

Date:

Faciliator:
Start/End Time:
E-mail Address
School

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Name

Signature

Check
if PSD

Other

Check if in
final four
years of
career
Time In

16

Time
Out