INTRODUCTION Response to Instruction (RtI) integrates core instruction, assessment, and intervention within a multi-tiered system to maximize student achievement and reduce behavior problems. Through the implementation of RtI, schools identify and monitor students at risk, use problem-solving and data-based decision making to provide research-based interventions and adjust the intensity of intervention based on the student’s response. RtI interventions are intended for students who are not responding to core or strategic instruction and interventions. A decision to move a student to research-based interventions is determined by a problem-solving team (PST) after several documented individualized interventions in the classroom have resulted in limited progress. Decisions regarding RtI intervention services are based on diagnostic assessments and progress monitoring. Plans should be made by the team to review student progress on a regular basis in order to make timely instructional decisions. Materials and strategies should be specialized research or evidence-based interventions based on the needs of the students who will receive the interventions. The ACC and Federal laws and regulations specify that parents of students receiving interventions must be notified periodically of specific progress made by the student. The progress monitoring data discussed at the monthly PST meetings along with PST recommendations should be shared with parents. A Parent Notification of Intervention Letter should be sent to parents by the PST within one week of initiation of intervention. It is suggested that an Intervention Progress Report be sent to the parent at regular intervals. DIRECTIONS FOR COMPLETING SECTION I Referring teacher completes student information at the top of the page and enters the date of completion. Work Samples: Attach representative samples of classwork (teacher lead and independent student work) and homework assignments. Classroom Tests: Attach student tests (i.e., weekly and/or end-of-chapter/unit classroom tests). Behavior Assessment: Attach teacher’s anecdotal notes, discipline referrals, suspension letters, etc. Current Classroom Performance Indicators: Attach written projects, teacher’s notes related to non- written projects (i.e., exhibits, recitations). Current Grades/Averages: Attach a copy of the student’s current report card or progress reports or list scores. Cumulative Folder Summary: Attach a copy of the student’s most recent standardized assessment results or list scores. Other Information: Additional information from the referring teacher, other teachers, counselors, and administrators. Parent Input: Attach information provided by the parent/guardian to the referring teacher. 2010 – 2011 RESPONSE TO INSTRUCTION Problem Solving Team (PST) Student Intervention Plan Form SECTION I.: DOCUMENTATION OF CONCERN(S) & DURATION OF INTERVENTION(S) [Completed by the teacher(s) of the class where the concern(s) exist(s)] Student’s Name: _________________________ Sex: Race: _________ Date: __________________ School: Code: Grade: Age: ____ Birth date: ____________________ Specific Concern(s): Specific Screening/Benchmark Data: Hearing Screening Date:_____________Pass______Fail______ Vision Screening (near) Date:________Pass____Fail___ Vision Screening (far) Date: ______Pass ______Fail Teacher(s) Referring Student: _____________________________________________________________________ Evidence of Concern(s) and Duration of Classroom Intervention(s) (Attach documentation for each category.) Evaluation Method Observation/Information Dates (From - To) Work samples: (classwork & homework) Classroom tests: Behavior assessment: (baseline data) Current classroom performance indicators: Current grades/averages: Other information: Parent input: DIRECTIONS FOR COMPLETING SECTION II Duplicate this page as needed. The information required in Section II should be completed by the PST team at the initial meeting for the student, and a copy given to the referring teacher for implementation to begin the following day. Record the date of initial team meeting on the referred student. Record the student’s name in the appropriate space. Record the teacher(s) responsible for implementation of research-based interventions. Identified Concern(s) to be Addressed: Check all of the categories to be addressed by the team. Choose as many concerns as applicable. Types of Interventions: Check all of the categories that apply. The accommodations which were listed in the BBSST Manual will not meet the scientific, research-based intervention requirements included in current laws and regulations. As accommodations do not represent scientific, research-based interventions; they are not to be included in the interventions considered by a PST. While accommodations do not improve student skills and are not considered to represent scientific, research-based interventions, any teacher may elect to employ accommodations when they seem appropriate for use with any student. Narrative of methods/strategies: Provide a narrative of the research-based methods and strategies used in the intervention plan. Include the number of days and amount of time that intervention will occur. Intervention Materials: List all materials necessary for the successful implementation of intervention. Planned Location: Record the setting in which the plan will be implemented Planned Method(s) of Monitoring Progress: Indicate how the student’s progress will be monitored by the team and the administrator. Intervention Goal: Planned Criteria (measurable) for Success/Termination of Intervention: Establish goals that would indicate progress or the lack thereof. Planned Beginning Date: Record the date on which interventions will begin. (This date should be the next school day following this meeting.) Planned Monitoring Date: Record the date on which interventions will be monitored.(This date should be at least monthly.) SECTION II. DOCUMENTATION OF INTERVENTION PLAN Date: ________________ (Completed by Problem Solving Team) Student's Name: Teacher(s) Responsible for Intervention Implementation: Identified Concern(s) to be Addressed (Choose one or more from the following): [ ] 01 Reading [ ] 02 Math [ ] 03 Behavior Intervention Plan Types of Interventions: (Choose all that apply.) Must include scientific, research-based instruction and intervention. [ ] Reading: Word-Level Intervention [ ] Reading: Comprehension Intervention [ ] Math: Computation Intervention [ ] Math: Reasoning/Problem Solving Intervention [ ] Behavior Intervention [ ] Other Intervention *The accommodations which were listed in the BBSST Manual will not meet the scientific, research-based intervention requirements included in current laws and regulations. As accommodations do not represent scientific, research-based interventions; they are not to be included in the interventions considered by a PST. While accommodations do not improve student skills and are not considered to represent scientific, research-based interventions, any teacher may elect to employ accommodations when they seem appropriate for use with any student. Narrative of methods/strategies: __________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Intervention Materials: __________ ______________ Planned Location: ____________________________________________________________________ Planned Method(s) of Monitoring Progress: Intervention Goal: In _______ weeks, the student will Planned Beginning Date:_______________________ Planned Monitoring Dates________________ _________________________________________________________________________________ DIRECTIONS FOR COMPLETING SECTION III Duplicate this page as needed. The information in Section III should be completed by the PST at the follow-up meetings to discuss and document the results of the interventions that were implemented. Date of Follow-up: Record the date the team meets again to discuss and document the results. This should occur at least monthly. Total Number of Days Implemented: Record the total number of days the plan was implemented. Outcome: Check one of the four categories that describe the outcome of the plan. Outcome Data and Results of Intervention: Give a brief narrative describing the outcome and results of the plan. The referring teacher should bring these results back to the team. Student Intervention Documentation: Provide evidence of the progress monitoring that occurred during the implementation of the plan. Recommendations for future action: Check one of the six categories that describe the team’s recommendations for future action. If ‘Other’ is checked, give a brief description. Signatures: Members of the Problem Solving Team sign under Section III (referring teacher, teacher responsible for intervention, and PST chair). SECTION IV * If referring the student to special education for testing, a Functional Assessment of the Classroom Environment (BASC) must be included with the Student Referral Form. SECTION III. Intervention Plan Review: Initiation Date: __________ (Plan to be reviewed at least monthly) Date of Follow-up: __________ Completion Date:________________________ Total Number of Days Implemented: _________ Outcome (Select one of the following): [ ] 1 Concern(s) better [ ] 2 No change [ ] 3 Concern(s) worse [ ] 4 Withdrawn from school Outcome Data and Results of Intervention (results brought back by the teacher): _________________________________________________________________ _____________ See Student Intervention Documentation for Additional Outcome Information. Recommendations for future action (e.g., release, continue interventions in another plan, try other specific interventions, or refer for special education evaluation or to another program): [ ] Release [ ] Continue interventions [ ] Try other specific interventions [ ] Refer for special education evaluation [ ] SOS/BASC completed [ ] Refer to another research –based program [ ] Other: ________________________________________________________________________ Signatures: Person(s) Responsible for Intervention (Teacher) Date Person(s) Responsible for Intervention (Teacher) Date Problem Solving Team Chair Date SECTION IV. IF REFERRING THE STUDENT FOR SPECIAL EDUCATION TESTING: General education shall complete a functional assessment of the classroom environment using an observation system such as the Behavior Assessment System for Children – (BASC – Student Observation System – SOS portion). General education teacher of the student and the special education teacher (serving in an advisory capacity of the team) shall complete the referral papers for the special education testing to begin, and it is recommended that the vision and hearing screening be a part of this process. Answer the following questions. 1. Does the data support that the reason for referral has a direct impact on the student’s education performance, or for a preschool child, participation in age appropriate activities? 2. Does the data support eh severity of the reason for referral? 3. Does the data support the duration of the reason for referral? 4. Does the data support the valid implementation of intervention(s) for the referral concern(s)? (e.g., appropriate target behavior, relationship of intervention to target behavior,, duration of intervention, integrity of implementation, data collection procedures? 5. Does the data support the ineffectiveness of the intervention(s) for the referral concern(s)? 6. Does the data include multiple sources of information about the reason for referral?