North Carolina Department of Public Instruction Responsiveness to Instruction/Multi-Tier System of Supports

School: Student Name(s)/Grade Level: Pick One: Tier I Tier II Tier III Tier II or Tier III only: Has the student had excessive absences/tardies/transience in their school career (if yes, attach relevant attendance history)? Student Strengths: Date: / /

Yes

No

What should our students know and be able to do?

Identify the Problem:

RIOT Review, Interview, Observe, Test

Develop and Test Hypotheses (Why is the problem occurring?) Instruction: Curriculum: Environment: Learner (Tiers II and III):

Instruction Assessment Plan/Results:

Curriculum Assessment Plan/Results:

Environment Assessment Plan/Results:

Learner Assessment Plan/Results:

Precise Problem Statement:

Discuss and Select Solutions:

North Carolina Department of Public Instruction Responsiveness to Instruction/Multi-Tier System of Supports

Develop and Implement Action Plan: Who? What? Where? How Often?

Baseline Score:

How will we know students are learning?

Measurement Strategy: Who? Data-Based Decision Making Rules: If Review Date: With What? then How Often?

Short Term Goal: Long Term Goal:

Think SMART

North Carolina Department of Public Instruction Responsiveness to Instruction/Multi-Tier System of Supports

Evaluate and Revise the Plan Date: Results: Participants (Name and Title):

How will we respond when students dont learn?

Next Steps:

How will we respond when students have already learned?

Parent Involvement in Plan Development:

Conference

Phone Call

Signed letter returned from home Date:

Other:

Parent Signature (if applicable): ________________________________________________

Meeting Notes (Optional):

North Carolina Department of Public Instruction Responsiveness to Instruction/Multi-Tier System of Supports

Evaluate and Revise the Plan Date: Results: Participants (Name and Title):

How will we respond when students dont learn?

Next Steps:

How will we respond when students have already learned?

Parent Involvement in Plan Development:

Conference

Phone Call

Signed letter returned from home Date:

Other:

Parent Signature (if applicable): ________________________________________________

Meeting Notes (Optional):

North Carolina Department of Public Instruction Responsiveness to Instruction/Multi-Tier System of Supports

Evaluate and Revise the Plan Date: Results: Participants (Name and Title):

How will we respond when students dont learn?

Next Steps:

How will we respond when students have already learned?

Parent Involvement in Plan Development:

Conference

Phone Call

Signed letter returned from home Date:

Other:

Parent Signature (if applicable): ________________________________________________

Meeting Notes (Optional):