University of Phoenix Material

Sample Response to Intervention (RTI) Forms

Student (Pseudonym): ____Paige D.____ _________
Campus: ___Upper School____________
Teacher: __Mr. Keys_- Science teacher___
Grade/Placement: __10___

Age: _16____

Ongoing Academic/Behavior Intervention Plan

Date:
Reading
Level:
Content
Area
Level:

Baseline Assessment
9/10/15
MAP: 206
Paraphrasing journal:
2/6
Math MAP: 200
Grade 9 Exam:
55/100

Review 1
10/29/15
Paraphrasing
journal: 4/6

Review 2
12/17/15
Paraphrasing
journal: 5/6

Unit 2 exam:
75/100
Timed test: 70/100

Unit 4 exam:
71/100
Timed test: 81/100

Reading: Lexile Measure/WCPM

Review 3
2/18/16
MAP: 212
Paraphrasing journal:
5/6
MAP: 207
Unit 6 exam: 74/100

Content Area: Field-Appropriate Measure

Log

Date
9/17/15

Target Area
(Academic or
Behavior)
Reading
comprehension

9/24/15

Reading
comprehension

10/1/15

Reading
comprehension

10/8/15

Reading
comprehension

Intervention
(Description)
Activating
prior
knowledge answering
questions
about text
topic
Summarizing
text from
previous
session
Activating
prior
knowledge
developing
questions
about new
text.
Summarizing
text from
previous

Academic
Behavior
(Monitoring
Frequency)
Once per
week

Reading
specialist

Text
selection
from 9/17/15
session
Text
selection
about
projectile
motion (Mr.
Keys)

Once per
week

Reading
specialist

Once per
week

Reading
specialist

Created 4
questions about
text based on
title and pictures
in text.

Text
selection
from 10/1/15

Once per
week

Reading
specialist

Wrote summary
about projectile
motion.

Resources
Questions
prepared
from science
text (Mr.
Keys)

Person(s)
Responsible

Notes
Mr. Keys wrote
questions about
falling motion
(dropping things,
throwing up in
the air, etc.) to fit
text selection.
Wrote summary
about falling
motion.

session
Activating
prior
knowledge answering
questions
about text
topic
Summarizing
text from
previous
session

10/15/15

Reading
comprehension

10/22/15

Reading
comprehension

9/21/15

Mathematics

Arithmetic
Fluency

9/28/15

Mathematics
problem
solving

10/5/15

session
Questions
prepared
from science
text (Mr.
Keys)

Once per
week

Reading
specialist

Mr. Keys wrote

questions about
Newtons 3 laws
to fit text
selection.

Text
selection
from
10/15/15
session
Timed tests
Math
Minutes
pages
SUMS
lesson

Once per
week

Reading
specialist

Wrote summary
about Newtons
3 laws.

Once per
week

Math
specialist
(tutor)

Problem
solving
strategies

SUMS
lesson
learning new
strategies

Once per
week

Math
specialist
(tutor)

Mathematics

Arithmetic
Fluency

Once per
week

Math
specialist
(tutor)

10/12/15

Mathematics
problem
solving

Problem
solving
strategies

Timed tests
Math
Minutes
pages
SUMS
lesson
SUMS
lesson;
current math
lesson

First two timed

tests were <50%
complete/correct.
Worked on
mental math tips
and tricks.
Completed
SUMS lesson
Completed
SUMS lesson.
Looked at
applying
strategies to
current
homework.
Completed
SUMS lesson
and two timed
tests.

Once per
week

Math
specialist
(tutor)

10/19/15

Mathematics

Arithmetic
Fluency

Timed tests
Math
Minutes
pages
SUMS
lesson

Once per
week

Math
specialist
(tutor)

10/26/15

Mathematics
problem
solving

Problem
solving
strategies

Current
math lesson

Once per
week

Math
specialist
(tutor)

Word problems
provided by
math teacher for
practice with new
strategies
Two timed tests
already nearing
70%
complete/correct!
Reviewed
material from
10/12/15
Used current
homework and
word problems
provided by
math teacher for
additional
practice.

Response to Intervention Time Line

Student Pseudonym: ___Paige D._____
Age: __16___

Grade: ___10___

6 Week Intervention

Begin Tier II Round 1

Intervention Notes:
o Paige has made great progress on her timed arithmetic tests, improving from
52/100 to 70/100 in a very short time.
o Paige is connecting with the texts and asking more questions every week. Her
summary journal on projectile motion included 4 out of 6 key points a
significant improvement over the first journal in September.

6 Week Intervention

Begin Tier II Round 2

Date: 10/29/15

Intervention Notes:
o Paige is now able to correctly complete over 80/100 questions on timed
arithmetic tests. Continued practice is still important, but her improvement is
excellent.
o Paige is working hard to use problem-solving strategies on her math word
problems. She is still struggling to determine the necessary steps, especially in
2-step problems.
o Paiges reading comprehension continues to improve. She particularly likes to
use graphic organizers for vocabulary and summarizing.

Begin Tier II Round 3

6 Week Intervention

Date: 9/17/2015

Date: 12/17/15

or Tier III
Intervention Notes:
o Paige is maintaining her arithmetic fluency rate of better than 80% on
timed tests.
o Paige is able to use problem-solving strategies with more consistency,
but she struggles to apply them when a new topic/unit begins.
o Paige is consistently employing pre-reading questioning and graphic
organizers while reading, and is writing summaries that include most or
all of the key points within a text selection. She has made wonderful
progress in reading comprehension, and the team recommends that RTI
interventions are no longer necessary for reading.