MTSS Academic Checklist

** Please continue this same form throughout the tiering process- file in data notebook**
Bring to MTSS meetings: Checklist, Data Notebook and Current Progress Report
Student Name: _________________________________ DOB: __________________ Grade: _________________________
Teacher: _________________________________ELL: ____________SP/L: ____________ Retention Grade: ____________
Reading: Tier 2 Implementation Date: __________________________Tier 3 Implementation Date: _____________________

Print: 1-i-ready Reading/Math Individual Student Report

Attendance
Date MTSS:

Tardies/Absence

_______

________/_________

_______

________/_________

_______

________/_________

_______

________/_________

_______

________/_________

2-Enhanced multi-class progress report w/all fields printed

except absences
Reading i-Ready ________ ________ _______ _______
Math i-Ready ________ ________ _______ _______
DRA Scores: ________ ________ _______ _______
ORF Scores: ________ ________ ________ _______
PASI/PSI Skills: _______ _______ _______ _______

Reading Tier 1 ---- Tier 2

Reading Tier 2---- Tier 3

Parent notification #1 (attach conference form)

Parent notification #2 (attach conference form)

Dates attempted: __________ _________ __________

Dates attempted: __________ _________ __________

Methods: Note

Methods: Note

Email

Phone Call

Notes in Planner

Academic Interventions (teacher implemented)

minimum of 6 weeks:
Specific area of concern (skills)
______________________________________________

Multiple guided practice opportunities for newly

learned concepts
Differentiated Instruction- to address students
preferred learning style

Email

Phone Call

Notes in Planner

Tier 2 interventions for a minimum of 6 additional weeks

Current data entered into EdInsight
Data trend line is flat or decreasing (EdInsight)
Collaborate with colleague(s)
Evidence/Three to five work samples
Passed hearing/vision screening (within 12 months)

Flexible Remediation
Peer tutoring
Use of manipulatives
Small group work
Increase opportunities to participate in active
academic responding
Increased amount of prompts/cues
Collaborate with colleague(s)
Evidence/Three to five work samples
Homework Club
21st Century

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text]

Tier 3 ----- Student Study Referral

Parent notification #3 (attach conference form)
Dates attempted: __________ _________ __________
Methods: Note

Email

Phone Call

Notes in Planner

Start date blue SST folder ____________________________

Due date blue SST folder_____________________________

[Type
text]
* SST
process does not start until blue folder is returned [Type text]

Math: Tier 2 Implementation Date______________________ Tier 3 Implementation Date: ____________________________

Math Tier 1 ---- Tier 2

Math Tier 2---- Tier 3

Parent notification #1 (attach conference form)

Parent notification #2 (attach conference form)

Dates attempted: __________ _________ __________

Dates attempted: __________ _________ __________

Methods: Note

Methods: Note

Email

Phone Call

Notes in Planner

Academic Interventions (teacher implemented)

minimum of 6 weeks:

Specific area of concern (skills)

______________________________________________

Multiple guided practice opportunities for newly

learned concepts
Differentiated Instruction- to address students
preferred learning style

Email

Phone Call

Notes in Planner

Tier 2 interventions for a minimum of 6 additional weeks

Current data entered into EdInsight
Data trend line is flat or decreasing (EdInsight)
Collaborate with colleague(s)
Evidence/Three to five work samples
Passed hearing/vision screening (within 12 months)

Flexible Remediation
Peer tutoring
Use of manipulatives
Small group work
Increase opportunities to participate in active
academic responding
Increased amount of prompts/cues
Collaborate with colleague(s)
Evidence/Three to five work Samples
Homework Club
21st Century

Notes:

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