RTI CHECK-LIST

In an attempt to work with you to create possible interventions to help this student increase their performance in your class, the Problem Solving Team (PST) would like to know some of the interventions you may have already tried, while also providing you with some new ideas/ interventions to try with this student.

Please fill out the form below.

 

Student First Name:     Student Last Name:       Student ID#: 

 

 Teacher Name:          Counselor:           Administrator:  

What is your hypothesis for why this student is currently struggling?

(Please carefully select all that apply; this can't be undone unless you refresh the webpage)

 

Attendance    Poor Homework Completion    Low Test Scores   Organization
Behavior Issues   Lack of Effort   No Participation   Focus   
Other:  

What have you Tried?

Strongly suggested:

  Contacted the student's parent(s) # of times  Date(s) 
  Contacted the student’s counselor # of times  Date(s) 
  Met with the student individually # of times  Date(s) 

Other Options:

Given the student a pass to the tutoring center during student's lunch or study hall period
Suggested after school tutoring in Rm. 2 on Tues, Wed, and/or Thursdays (3-5pm)
Moved the student’s seat (proximity control)
Checked with student to make sure they are writing the assignments down
Provided the student with review/study sheets and/or guided notes
Assigned a peer buddy in the class to provide the student with extra help
Provided the student with extra or follow-up materials in the area they are struggling
Held review sessions for all students that are struggling
Provide student with a rubric for the assignments
  Other: 
           Comments from the above interventions you have implemented with this student:
        

  

© Taylor Morello, FHS School Psychologist
Webmaster:  Tony Miller, Assistant Principal
William Fremd High School, Palatine, IL  60067
Last Revised:  11/20/2009