Rti Tracking Sheet

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North Clackamas School District
RTI Tracking Sheet
Attach all relevant data (e.g., DIBELS) and attendance sheet from interventions.
Student Name: ________________________ Grade: ______ School: ______________________
Area(s) of Concern: ____________________________________ Level on ELPA (1-5): ________
Most Recent OAKS Scores (grade taken: ____): R/L _____
M ____
Wr. ____
Sci. _____
Tier II - Intervention 1
: _______________________
End Date: ________________________
Start Date
: ___________________________________________________________________
Intervention
Group Size: Individual ____
2-5 ____
6-15 ____
Frequency:
Times per week _____
Duration:
10 min ____
15 min ____
20 min ____
30 min ____
45 min ____
Team Decision/Next Steps: ____________________________________________________
Tier II - Intervention 2
Start Date: ______________________
End Date: ________________________
Intervention: __________________________________________________________________
Group Size: Individual ____
2-5 ____
6-15 ____
Frequency:
Times per week _____
Duration:
10 min ____
15 min ____
20 min ____
30 min ____
45 min ____
Team Decision/Next Steps: ______________________________________________________
Tier III
Start Date: ______________________
End Date: _____________________
Intervention: __________________________________________________________________
Group Size: Individual ____
2-5 ____
6-15 ____
Frequency:
Times per week _____
Duration:
10 min ____
15 min ____
20 min ____
30 min ____
45 min ____
Team Decision/Next Steps: ____________________________________________________
Date
Notes
Fill out for each student receiving interventions.
. This form and a fillable version can be found on the RTI website. From the NCSD
homepage ( ), click on Departments → Response to Intervention →Tier II, or Fillable Forms.
Version 01/14/10

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