Appendix B Problem-Solving/RtI Worksheet (For Individual Student Concerns)
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1 Appendix B Problem-Solving/RtI Worksheet (For Individual Student Concerns) Date School Student Grade Teacher General description of concern: STEP I Problem Identification: What is the problem? 1. What is the benchmark/expected level of performance? 2. What is the student s current level of performance? (Be sure to include data that directly assesses the target skill you want the student to perform.) 3. What is the peer level of performance? 4. What percentage of students in the classroom demonstrate this discrepancy? 5. Gap Analysis: Benchmark & Student Benchmark & Peer Peer & Student 6. What is the replacement behavior or target skill? (measurable, observable, reportable) 7. At what tier will this problem be addressed? (circle one) Tier 1, Tier 2, Tier 3 8. Do we have enough information to complete Problem Identification? If yes, go to Problem Analysis. If no, what information is still needed? When will we meet again? 71
2 STEP II: Problem Analysis: Why is it occurring? Replacement behavior or target skill (from #6, Section 1: Problem Identification) Based on available data (gathered through review, interview, observation, testing), why do you think the replacement behavior is not occurring and what is the predicted result of actions you might take? Below, record each hypothesis for why the replacement behavior is not occurring along with its matched prediction statement. Provide any data used to validate or refute each hypothesis, and circle Yes to indicate that the data supported the hypothesis or No to indicate that it did not. Hypothesis (What are the most likely reasons this problem is occurring? address potential domains of instruction, curriculum, environment, learner) Prediction Statement (Based upon what we ve learned, what could be changed about the instruction, curriculum, and/or environment in order to enable the student to learn?) The problem is occurring because. If would occur, then the problem would be reduced. Hypothesis 1: Prediction Statement 1: Hypothesis 2: Prediction Statement 2: Hypothesis 3: Prediction Statement 3: Hypothesis 4: Prediction Statement 4: Do we have enough information to complete Problem Analysis? If yes, go to Intervention Implementation If no, what information is still needed? When will we meet again? 72
3 Step III: Intervention Implementation: What are we going to do about it? Comprehensive Intervention Plan Worksheet Who is the intervention plan being developed for? What is the replacement behavior/target skill? What is the expected level of performance? What is the current level of performance? Verified Hypotheses Intervention Plan Support Plan Monitoring Fidelity Monitoring Plan for Determining Student Progress What data will be collected and how often? How will we decide if the plan is effective? How will data be shared? 73
4 74 Example Comprehensive Intervention Plan Worksheet Who is the intervention plan being developed for? Randy What is the replacement behavior/target skill? Reading Accuracy What is the expected level of performance? 95% Accuracy on grade-level material What is the current level of performance? 76% Accuracy on grade-level material Verified Hypotheses Intervention Plan Support Plan Monitoring Fidelity Monitoring Plan for Determining Student Progress Randy does not selfmonitor while reading connected text. 30 min lessons: 5 min warm up (phonics) 20 min (fluency & selfmonitoring-tapping at word, sentence, then paragraph level) 5 min comprehension MWF 9:20 to 9:50 3rd grade intervention room Mark classroom teacher First 2 weeks meet with Suzanne 3 times/week(mwf) Second 2 weeks meet with Suzanne 2 times/week (MW) Following weeks meet with Suzanne once per week(m) 10:00 am during 3rd grade planning time Suzanne s intervention room The Intervention Doc. Worksheet (IDW) will be used to record intervention sessions Directly after every scheduled intervention session How will data be shared? The IDW will be shared at the student data review meetings described in Monitoring Plan column of this worksheet. What data will be collected and how often? Oral reading fluency and accuracy will be collected on Friday of each week using grade level CBM probes. How will we decide if the plan is effective? Graphed data will be reviewed at regularly scheduled individual student data review meetings on 12/11/09 and 1/8/10 and response will be evaluated as Positive, Questionable, or Poor.
5 Step IV Response to Instruction/Intervention: Is the plan working? Attach graphed data for each review date: Review Date: Is the response to instruction/intervention Positive, Questionable, or Poor? 1. If Positive: Continue current instructional supports. Adjust goal upward. Fade supports. 2. If Questionable: Was intervention/instruction implemented as planned? Yes No If no, what strategies will be utilized to increase implementation? If yes, should intervention intensity be increased? Yes No 3. If Poor: Was intervention/instruction implemented as planned? Yes No If no, what strategies will be utilized to increase implementation? If yes, was instruction/intervention aligned with the verified hypothesis, or is there other aligned instruction/intervention to consider? Are there other hypotheses to consider? Was the problem identified correctly? 75
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