Response to Intervention Problem Solving Process

Name and Position of Teachers on Team: Classroom teacher), Title 1, Counselor, Psychologist, Occupational
Therapist, Principal, Math teacher, ELL, SPED, Para
Name of Student:_C___________________ Date:_10/13/2015_________________________

STEP 1: Gather and Review Existing Data

This step should be a summary of data that has already been collected, so, that all team members have a clear
understanding of the students profile and current situation. Should include (if relevant to identified problem):

Basic student info,

Summative standardized test results (i.e. TCAP, NWEA MAP, district assessments, etc.)
Formative assessment results (DIBELS progress monitoring, Curriculum Based Measures, classroom
assessments, etc)
Health history information (vision, hearing, medical, etc)
Behavior/discipline history
Current instruction being implemented (strategies, interventions, special programs, IEP or ILPs, READ
Plan, etc.) i.e. What has already been tried?

If you do not already have a form, which includes the above information, you can use the one that follows
(Response to Intervention Student Data Summary), or you can make a similar one to fit your particular school.

Response to Intervention Student Data Summary

This summary is used to complete step 1 of the Response to Intervention Problem Solving Process

Name of Student:__C______ Date:_10/13/2015____________________

DOB:_Confidential________ Age:__10___ Grade:_5th____ Teacher/Counselor:_Ms. S.______________
Primary Home Language:_English_______________________ (Attach home language survey if applicable)
Parents/Guardian: Mr. and Ms. L________________________________ Phone#_______
Address:__Confidential ______________________________________________________________
e-mail___Confidential_______________________________
Date(s) Parents Contacted About Concerns:_9/16, emails weekly since 9/16________________
Parents Input: (attach any applicable documents)?
Parents have been informed and are aware of interventions and strategies in place.
CURRENT INFORMATION
Current Grades/Classroom Functioning:
CL has not been completing work. He lays his head on his desk and draws on his worksheets. CL has a difficult
time interacting and socializing with peers. He will often hit, poke, kick and say inappropriate things to his
peers.
Describe Strategies/Interventions/Special Programs Currently Being Implemented or in Past Including
504 or Special Education or Attach ILPs:
Concern

Behavior

Strategy/Intervention
/Program
Positive Behavior Chart
with rewards
Meets with consoler
Has meet and been
observed by school
psychologist

Dates

9/21-10/13
Once a week
9/30, 10/14

Student Response
(include data when
available)
Student has shown less
behavior issues with
other students since
behavior chart has
begun

Writing

One on one with title 1

teacher
One on one with a para
in the classroom

Everyday starting 9/21present

Works well one on one

with a teacher, teacher
will help him write/type

Reading

One on One with title 1

teacher
One on one with a para
in the classroom

Everyday starting 9/21present

Sometimes completes
work when working one
on one with a
teacher/para

HEALTH HISTORY
Vision Assessment: None___ Partial___ Complete :30/20 Right eye 20/40 Left eye Student has stigmatism and has prescription
glasses, but does not wear them in school.
Hearing Assessment: None___ Partial___ Complete: passed test, normal
Nurse Visits: # of visits_4____ Summary of concerns: _bloody nose, hurt rib, hurt stomach
Significant Medical History:_None_____________________________________________________________
Physical Health Concerns:__None_____________________________________________________________
Psychiatric/Mental Health History:_None_______________________________________________________
Medications (Names, dosage, doctors)_None______________________________________________________
SCHOOL HISTORY
Years in School (pre K-12) 4th-5th

(Home schooled k-3rd)

Number of Schools Attended___1______ Grades Repeated:__none_____

Attendance Concerns: No____ Yes_x___ If yes, to what degree: Student has a lot of absences

Summative and Formative Assessment Results (TCAP, NWEA, DIBELS, CBM, Classroom, etc)
SUBJECT

Year/Test/Result

Reading

12/23/15/Readin FAST/499! (At risk)

Math

1/13/15/Math FAST/208!! (High risk)

Writing

10/13/15/Spelling/ 1 correct out of 7

Other:

Discipline/Behavior History

Year/Test/Result

Year/Test/Result

None Yes, Dates

Description of incident or concerns

Current Referrals to
Office

9/8,9/10,9/15,9/17 Student hit other students and used inappropriate

language and actions towards peers on several
occasions.

Current Classroom
Behavior Observations

9/21. 9/25,9/30,
10/4, 10/13

Suspensions

Expulsions

Student gains attention from peers by poking,

hitting, touching etc. CL fidgets with anything he
can find, is often tired and hungry, lacks
motivation, lays head down on desk, draws pictures
on his worksheets

List Additional Agencies, Practitioners, etc. Providing Services for the Student/Family:

Agency

Contact Information

Date of Service

Nature of Service

STAR Center
Sensory Therapies and
Research

5420 Quebec St.

Greenwood Village, CO
80111
303-221-7827

12/9/2013

Occupational Therapy
Initial Assessment

Other Pertinent Information:

Form adapted from Cherry Creek School District, Student Achievement Services, July 2005

Response to Intervention Problem Solving Process

STEP 2: Analyze and Interpret Data & Problem
According to the data, what are this student's strengths?
C is sensitive, artistic; he is compassionate and helps a peer with autism in the class. He has good motor
planning and creative ways to problem solve and has strong perseverance when facing just right challenges or
when he is invested in an activity. When motivated with a reward he tries hard to be well behaved.
According to the data, what are the primary concerns?
C missed a large amount of elementary school- K-3rd; he is behind in all academic areas. He was

homeschooled by his mother. Behavior is the primary concern because this is getting in the way of his learning.
He finds it challenging to respect others personal space and is always in his peers space. He gets angry,
destructive, and verbally aggressive when he is upset. He has a hard time maintaining friendships because of
this. Other concerns are his academics, specifically reading, writing, and math.
Clarify the Concern
Write a discrepancy statement (e.g. Student is reading x words per minute on 3rd grade material and his peers
are reading x words per minute on 3rd grade material):
Student is reading on average 8owcpm on 5th grade FAST CBMreading assessment. He is reading at the 5th
percentile out of 95% based on the CBMreading FAST assessment.
Student is acting out towards peers violently/inappropriately 2-3 times a day.
Student is not doing or completing work and his peers are completing and turning in work.
Student draws on worksheets and papers instead of completing assignments.
What would you like the student to do that he/she is not presently doing? (written it in observable and
measurable terms.)
By the end of the trimester 11/20/1015 student will read 130wcpm.
By the end of the month student will wear his glasses 100% of the time while reading.
By the end of the month student will refrain from violent/inappropriate actions towards peers through out each
day of the week while in school.
By the end of the month student will write two sentences for writing, and make an effort to complete tasks.

Problem Analysis
Reasons for the Academic Discrepancy (Why): The discrepancy occurs because of problems with...

Instruction:

methods of instruction

Curriculum:

content

Environment:

physical arrangement

behavior management
Learner:
study skills

assessment procedures

sequencing

pacing

peers

routines

level of difficulty
furniture/equipment

student's expected response to instruction

requirements for prior knowledge/skills
materials/resources

expectations

other

academic skills
social skills

motivation

learning strategies

learning styles

learning rate

ability/aptitude

pre-requisite knowledge/skills

SKILL OR PERFORMANCE PROBLEM?

_x_ Skill Problem? (Lacks skills: teach them.)

_x_ Performance Problem? (Has skills; doesn't perform them consistently: use motivational strategies)
ANY OTHER RELEVANT UNKNOWN INFORMATION NEEDED?
This student is adopted, has a history of behavior issues since a toddler. Because of these issues the mother decided to home
school. The student has been home schooled since kindergarten. Last year as a fourth grader was his first year back into the
school system. He is far behind academically, and has an extremely difficult time with his social and emotional skills and
interacting with peers.

rules

Response to Intervention Problem Solving Process

STEP 3: Generate Goals
A goal statement should be a specific description of change you expect to see in students behavior as a result of
the intervention.
Goal Statement:
Includes behavior to change
Conditions that will bring about change
Level of behavior that is expected
Long- term goals describe progress student is expected to make in a semester or year often
associated with a program or the scores/level a student needs in order to be proficient on grade
level expectations
Progress Goals (Short-term goals) describe progress student is expected to make in a short
period of time during an intervention period (period of time between administration of
progress monitoring assessments).
Examples of Goal Statements
Long-term In 30 weeks, when presented with random reading passages from Basic Skill
Builders, level 5, Sam will read aloud at a rate of 50 words correct per minute
Progress Goal (Short-term) Each week, when presented with a reading passage from Basic
Skill Builders, level 5, Sam will increase his oral reading rate by two words correct per minute
Goal Statements
Long-Term Goal:
In 30 weeks student C will increase his oral reading fluency score from 80wcpm to 150wcpm. When presented
with FAST reading passages, level 5, C will read aloud 150wcpm on the FAST oral reading assessment. Tier 3intervention support will help student increase his oral reading fluency score over the next 30 weeks.
Student will wear glasses while he reads 100% of the time.
Initial Progress Goal:
Each week, when presented with a reading passage from FAST Level 5, C will increase his oral reading fluency
rate by four words correct per minute on FAST CBMreading progress monitoring assessment. Raising his oral
reading fluency score from 80wcpm to 100wcpm from the time of tier 3-intervention support begins on October
15, 2015. Progress monitoring will continue each week using the FAST CBMreading measure through the end
of the trimester November 20, 2015. Student will wear glasses while he reads 100% of the time.

Response to Intervention Problem Solving Process

STEP 4: Assign & Implement an Intervention Plan and Monitor Progress
Use this sheet for planning purposes. Use the Collaborative Response to Intervention Plan Log for recording
the determined course of action. To complete this step:
Identify research-based intervention options:
Weekly progress monitoring
Behavior Chart with rewards
RtI Tier 3 instruction
One on One instruction with title 1 teacher
Para in the classroom to assist him one on one
Meets with Occupational Therapist once a week
Meets with counselor once a week.

Of the identified intervention options, which one(s) best matches the students needs, is most likely to
assist the student in meeting the goal, has the best chance of effectively being implemented by the school
(i.e. trained provider, schedule, available resources, etc.)
Weekly progress monitoring
Behavior Chart with rewards
RtI Tier 3 Instruction
Meets with Title 1 teacher daily during reading and writing
Has a para in the classroom with him at all times to help him get work done, motivate him, ques to stay on task
etc.

Progress monitoring tool(s) (What assessment will you administer to measure the students growth toward the
identified goal?):
Behavior Chart- to measure if his behavior is improving
FAST CBMReading oral fluency Assessment and progress monitoring

Intervention Period Schedule (What dates will you administer the progress monitoring assessments? What
dates will you meet with your team to discuss the students progress?)
Progress Monitoring Assessment Schedule:
FAST CBMreading oral Fluency Progress Monitoring- Every Wednesday

Behavior Chart everyday- + for good behavior and for bad behavior, if receives all + then he gets to go to oak
on Friday afternoon.

Collaborative Meeting Schedule:

Meeting with RtI team once a month

Implement the intervention plan and progress monitor the students response. Use the Collaborative
Response to Intervention Plan Log to record the intervention strategies and the students progress.