Solutions Form

PART ONE: TEAM

Student(s): Grade: Date: Teacher: Parent/Contact Information:

PART TWO: DATA

A. Background Information *Print and attach Attendance, Grades, Discipline, and other pertinent information. B. Describe the Discrepancy UNIVERSAL SCREENING
Reading Math Language Behavior

SCREENING TOOL Date

Student Score (ile)

Norm (ile)

C. Additional Screeners *Consent for Screening Required Assessment Tool Student Score Norm Average

PART THREE: INTERVENTION

Instructional Need (Describe the Intervention Details)
Date Focus or Skill Teaching Strategies Arrangements Time Fidelity Check

PART FOUR: PROGRESS MONITORING

Progress Monitoring (Determine the Goal) *Attach Chart Including Aimline & Trendline Date CBM Baseline Norm Goal Monitored By

PART FIVE: DECISION MAKING

Response to Intervention Determination
The child made sufficient progress to meet age or State approved grade-level standards when using a process based on the childs response to scientific, research-based intervention. OR The child does not make sufficient progress to meet age or State approved gradelevel standards when using a process based on the childs response to scientific, research-based intervention: (Rate of Progress, Achievement Level, and Educational Need must ALL be answered yes to meet eligibility criteria) RATE OF PROGRESS, when given research-based intervention over time is significantly slower than expected or student maintains expected progress only with greater resources than general educational alone in the areas of concern? Yes (list area(s) and provide rate of progress data through written description) No (list area(s)) ACADEMIC ACHIEVEMENT LEVEL is significantly below expectations when compared to grade level peers in the area(s) of concern? Yes (list area(s) and provide discrepancy data thorough written description) No (list area(s)) EDUCATIONAL NEED requires services and support that extends beyond what typical general education resources alone can provide? Yes (list area(s) and provide resources used to determine need thorough written description) No (list area(s))