Notification Of Intervention And/or Informed Parent Consent For Rti Data Collection Form
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1NOTIFICATION OF INTERVENTION AND/OR
INFORMED PARENT CONSENT FOR (RtI) DATA COLLECTION
(Obtain prior to Tier II Movement)
Student: ________________________________ ID: _______________________________ DOB: __________________________
Grade: _______________________________Teacher/s: ____________________________________________________________
This document serves as notification that my child will be provided Tier II interventions in the area/s of: __________________.
I understand that the purpose of this recommendation is as follows:
Help my child improve his/her academic/behavioral/speech or language performance based on his/her individual strengths
o
and weaknesses.
Provide data for monitoring the effectiveness of applied interventions.
o
Provide data for determining when goals have been reached and when goals need to be changed.
o
Additionally, I understand that:
This is not a referral for Special Education or Section 504. However, if tiered strategies/interventions are unsuccessful in
o
helping my child to make adequate progress, a referral to dyslexia, Section 504, or Special Education may occur which will
require a separate written consent to be signed by me for the evaluation to proceed.
The information obtained through this process may be used as part of the eligibility determination process for Special
o
Education.
I will be invited to participate in each RtI Team meeting.
o
I will be provided with results of decisions based on the data collected.
o
Parent Notification of Tier II Intervention via: Student/Phone/Mail Notified by: _____________________Date: __________
Circle One
Staff Member
************************************************************************************************************
IFAPPLICABLE, I give my consent for school staff to conduct general education evaluations regarding my child’s academic
performance and academic strengths and weaknesses.
Staff who may gather data about my child include:
*Classroom Teacher
*Math Specialist
*Educational Diagnostician/LSSP
*Bilingual/ESL Teacher
*Counselor/Social Worker
*Psychologist
*Curriculum Instruction Coordinator (CIC)
*Nurse/Nurse Practitioner
*Behavior Specialist
*Reading Specialist
*Speech Language Pathologist/
*Autism Specialist
Therapist or Assistant SLP
The following professionals will conduct an observation of my child. Please INITIAL to indicate the following:
_______I give my permission for the Speech Language Pathologist/Therapist to conduct an observation/screening.
_______ I give my permission for the Educational Diagnostician/Licensed Specialist in School Psychology to conduct an
observation/screening.
_______ I give my permission for the Behavior Specialist to conduct an observation(s).
_______I give my permission for the Nurse Practitioner to conduct an observation/assessment and contact my child’s health
care provider for further information as needed.
_______ I HAVE RECEIVED A COPY OF THE RTI PLAN TO INCLUDE INFORMATION ON STRATEGIES AND
INTERVENTIONS IMPLEMENTED TO ASSIST MY CHILD.
_______I understand the notification/information provided in this consent and my questions about this process have been
answered. If I have any more questions, I can call: ___________________________at_____________________ for
more information.
RtI Coordinator
Campus Phone Number
Additional data may be collected through direct observation of my child’s classroom or school activities
o
and behaviors. All data collected is confidential and will be used only for the purposes described in this consent.
Results will be provided only to individuals directly involved in academic planning for my child.
THIS CONSENT IS VALID FOR ONE CALENDAR YEAR and will expire on _________________(date). I understand that I
may revoke this consent at any time by submitting written notice. I understand that any observations or screening conducted
prior to the withdrawal of my consent may be used by the district to address educational needs of my child.
__________________________________________________________________
_______________________________________________
Parent Signature
Date
______________________________________________________________
__________________________________________
Interpreter Signature
Date
______________________________________________________________
__________________________________________
Principal Signature
Date
SAISD C&I Department-RtI 8-Secondary
11 of 12
REVISED: 09/2009
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