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STUDENT

IAT
FOLDER
__________________________ ________________________ ________________________
School Year Teacher Grade Level

_________________________
Campus

Committee Members:

______________________________________ _____________________________________

________________________________________ _______________________________________

________________________________________ _______________________________________

________________________________________ _______________________________________

CONFIDENTIAL RECORDS
KEEP THIS FOLDER AND CONTENTS SECURE

The Family Educational Rights and Privacy Act (FERPA) is a federal law that guarantees the confidentiality of student records.
The information in this folder is confidential and can only be shared with the student, those individuals working with the student,
and/or the student's parent/guardian, unless express written permission has been given by the parent/guardian or adult
student.
REQUEST FOR RTI CONSIDERATION made by: Parent* Teacher
(Name) _

The student is experiencing difficulty in the following area(s):

SPEECH ACADEMICS ACADEMICS BEHAVIOR


(cont'd)
Organization
Articulation Reading Math Following Directions
Pragmatic Comprehension Basic Facts Work Refusal
Communication Decoding Problem Solving Verbal Aggression
Expressive Language Fluency Measurement Physical Aggression
Receptive Language Writing Social Studies Interaction w/Peers
Other Spelling Science and/or Adults
Sentence/Paragraph Construction Homework Other _
Capitalization/Punctuation Gifted & Talented
Other ________
For any area of concern, teacher must present data illustrating strategies already attempted, student's performance, and,
where applicable, work samples. (Attach teacher data)

MEDICATIONS
Is the student taking any medications? Yes No (If yes, list the types of medications, dosages and frequencies)
Medication Dosage Frequency

Has the parent signed a written release and consent to consult with the student's physician? Yes
No
If yes, attach a copy of the release to this folder.

SCREENINGS
Vision Screening Hearing Screening
Date Conducted: ________/________/_______ Date Conducted: ________/________/_______
Results: ___________________________________ Results: ___________________________________
Passed Failed Passed Failed

BENCHMARK SCORES Attach results


Reading Math Writing Social Studies Science
Score
Score
Score

DISTRICT READING INVENTORY Attach results


Lexile* Gr Equiv* Accuracy Level** Fluency** Comprehension**
BOY
MOY
EOY
* From Istation/Reading Inventory
** From Running Record

PARENT INFORMATION
The parent was sent a Parent Information Form on ______/______/______
The completed form was received by District:
Yes (Date of receipt: ______/______/______ ). Add copy of form to this folder.
No (Date additional copy was sent and/or parent contacted: ______/______/______ )
ATTENDANCE
As of ______/______/______ , the student has been absent _______ days this year and _______ days last school
year. The students attendance ______ is ______ is not affecting performance.

Has compulsory attendance been pursued? Yes No If yes, attach notice. If no, explain: ______________
_____________________________________________________________________________________________
*The use of RTI strategies cannot be used to delay or deny the provision of a full and individual evaluation. If the RTI team agrees with the parent who
refers the child for evaluation that the child may be a child eligible for special education and related services, the school must evaluate. In this instance,
place the child in TIER II interventions during the referral process, assess at reasonable intervals, and provide results to the parent(s).

If the parent requests special education testing and the IAT does not suspect that the child has a disability, the parent will receive a written response (Prior
Written Notice) communicating that there is no suspected disability, and procedural safeguards. Date provided _____/_______/______.

BEHAVIOR
The student has received disciplinary referrals this year: Yes No
If yes, add the disciplinary referrals to this folder.

The student has been placed in In-School Suspension (ISS) this year: Yes No
If yes, provide the dates and offenses that formed the basis of the placement:
Offense: __________________________________________________________ Date: ______/______/______
Offense: __________________________________________________________ Date: ______/______/______
Offense: __________________________________________________________ Date: ______/______/______

The student has been placed at an alternative education placement or expelled for disciplinary reasons: Yes No
If yes, provide the dates and offenses that formed the basis of the placement or expulsion:
Offense: __________________________________________________________ Date: ______/______/______
Offense: __________________________________________________________ Date: ______/______/______
DISCIPLINE REFERRALS
Problem Behavior (i.e., Replacement Behavior Interventions (i.e., Reinforcement
unwanted behavior) (I.e., desired behavior) Actions taken)

TEACHER ANECDOTAL NOTES


Anecdotal Notes added to the folder

Identified Dyslexic Students Direct Instruction ____ yrs Completed Monitoring


Program used _____________ Program used _____________
Accommodations __________________________________________________________________________________

TIE
Tier I Meeting Date: ______/______/______
Based upon the review of the team, the student needs to be screened for the following:
Speech Behavioral Interventions Dyslexia _______________________________
The IAT Team has determined that the student needs the following interventions, beginning ______/______/______:
Accommodations Accommodations folders/forms have been provided to teachers: Yes No
Behavior Intervention Plan
Social Skills Training for _______________________________________________________________________
Access to General Education Counseling to address _________________________________________________
Mentor
Tutoring
Other _____________________________________________________________________________________

PROGRESS MONITORING
The teacher(s) or service provider(s) shall maintain data to monitor the students performance. The success of these
interventions will be reviewed by the team at intervals of:
6 weeks 9 weeks 18 weeks Other _______________________________________
TIER I REVIEW
Following its review of the student, the team has determined that:
The interventions have been successful and the student no longer needs the interventions in TIER ONE.
The interventions have been successful and the student will continue with the interventions in TIER ONE.
The student needs additional interventions in TIER TWO.
The student needs to be evaluated for dyslexia. (Follow 504 procedures for consent)

Document in Chancery

TIER
Tier II Meeting Date: ______/______/______
The RTI Team has determined that the student needs the following interventions, beginning ______/______/______:
Continue Interventions Provided in Tier One
Accommodations Accommodations folders/forms have been provided to the teachers: Yes No
Tutoring Math Reading Writing Specify time: ________________________________
V
Small Group Reading Intervention Specify time:___________________________________________
Small Group Math Intervention Specify time:__________________________________________
Social Skills Training
Access to General Education Counseling to address ___________________________________________________
Mentor
Functional Behavioral Assessment*
Behavior Intervention Plan
Other _____________________________________________________________________

PROGRESS MONITORING
To determine effectiveness, these interventions will be reviewed by the team at intervals of
6 weeks 9 weeks 18 weeks Other _______________________________________
Goal 1 __________________________________________ Goal 2 ________________________________________
TIER II PROGRESS MONITORING FOR SPECIFIC INTERVENTIONS:
Date of Review Reading Progress Measurement Math Progress Measurement Other Progress Measurement

Following its review of the student, the team has determined that:
The interventions have been successful and the student no longer needs the interventions in TIER TWO.
The interventions have been successful and the student will continue with the interventions in TIER TWO.
The student needs additional interventions in TIER THREE
Document in Chancery
TIER
III______/______/______
Tier III Meeting Date:
The RTI Team has determined that the student needs the following interventions, beginning ______/______/______:
Continue Interventions Provided in Tier Two
Accommodations Accommodations folders/forms have been provided to the teachers: Yes No
Tutoring Math Reading Writing Specify time: ________________________________
v
Additional Reading Intervention Specify time: ___________________________________________
Additional Math Intervention Specify time: __________________________________________
Dyslexia Program Specify time: __________________________________________
Specific Goals and Objectives Attach to folder
Individualized Tutoring Referral to Special Education**
Functional Behavioral Assessment** Behavior Intervention Plan
Referral to Section 504 Other _________________________
Goal 1 __________________________________________ Goal 2 ________________________________________
TIER III PROGRESS MONITORING FOR SPECIFIC INTERVENTIONS:
Date of Review Reading Progress Measurement Math Progress Measurement Other Progress Measurement

Following its review of the student, the team has determined that:
The interventions have been successful and the student no longer needs the interventions in TIER THREE.
The interventions have been successful and the student will continue with the interventions in TIER THREE.
The student needs additional interventions in TIER THREE.
* When a student is in Tier II or III, academic performance needs to be assessed at reasonable intervals and the results
provided to the parents.
** Written parental consent must be obtained.
*** The referral MUST be submitted for review prior to obtaining written consent for evaluation.
Document in Chancery