MTSS Problem Solving for GMS

Student name

Grade level

Meeting Attendees

Intervention Start Date

Additional meeting
dates.

Date of changes to
interventions made

Date of Parent Contact

Guardian name and #

Parental information

Health History:
medication, Vision,
Hearing Concerns

Student’s Attendance
History

Behavior data Minors:

Majors:
In-School Suspension:
Out-of-School Suspension:
Other:

Student strengths,
interest, preferences

How student best

learns (Visual, small
group, repetition)

Area(s) of concern (as

specific as possible)

Current interventions,
accommodations and
modifications

The Subject of Concern

Classroom teacher and
content

Arrangement,
 environment, materials
etc.

Students strengths,
interest and
preferences pertaining
to this subject.

Standards taught

Standards of concern

Tiered Supplemental Instruction (WIN)

Teacher and subject

Location, frequency,
duration

Arrangement,
environment, etc.

Standards being
addressed (Goal)

Materials and
research-based
instruction

Additional
recommendations for
accommodations and
modifications

Progress Monitoring
Data will be graphed once per week.

Data will be reviewed every…...

When data does not support meeting the goal or lack of progress for 7-9 data points, the team will need to
determine next steps (continuing intervention, change in goal, move to suspect disability, etc)

Conclusion observation information at the end of the intervention

Successful interventions:

Unsuccessful interventions:

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