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PS- RtI Worksheet

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Guiding Tools for Instructional Problem Solving – Revised (GTIPS-R)
Problem-solving/RtI Worksheet
(For Individual Student Concerns)
Note: This is a digital form. If you are working in a web browser, you can print the information that you enter in
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Date: School:
Student: Grade: Teacher:
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.)
4 What percentage of students in the classroom demonstrate this discrepancy?
Generaldescri
p
tionofconcern:
3. Whatisthepeerlevelofperformance?
Guiding T
ools for Instructional Problem Solving – Revised (GTIPS-R)
5 Gap Analysis:
Benchmark & Student: _________________________________________________________
Benchmark & Peer: _________________________________________________________
Peer & Student: _________________________________________________________
6. What is the replacement behavior or target skill? (m
easurable, observable, reportable)
7. At what tier will this problem be addressed? (check)
Tier 1
Tier 2
Tier 3
8. Do we have enoug
h information to complete Problem
Identification?
Yes
No
Ifyes,gotoProblemAnalysis
Ifno,whatinformationisstillneeded?
Whenwillwemeetagain?
Guiding T
ools for Instructional Problem Solving – Revised (GTIPS-R)
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 check 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
could is occurring? – address potential domains of
curriculum, instruction, curriculum, environment,
learner)
Prediction Statement
(Based upon what we’ve learned, what be
changed about the instruction, 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:
Validated: Yes
No
Prediction Statement:
Relevant Data:
Guiding Tools for Instructional Problem Solving – Revised (GTIPS-R)
Validated: Yes
No
Validated: Yes
No
Hypothesis 2:
Prediction Statement 2:
Relevant Data:
Hypothesis 3:
Prediction Statement 3:
Relevant Data:
Guiding Tools for Instructional Problem Solving – Revised (GTIPS-R)
Validated: Yes
No
Do we have enough information to complete Problem Analysis?
If no, what information is still needed?
Hypothesis 4:
Prediction Statement 4:
Relevant Data:
If yes, go to
Intervention Implementation
When will we meet again?
Guiding Tools for Instructional Problem Solving – Revised (GTIPS-R)
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
Who is responsible? Who is responsible? Who is responsible? Who is
responsible?
What will be done? What will be done? What will be done? What data will be
collected and how
often?
When will it occur? When will it occur? When will it occur? How will we
decide if the plan is
effective?
Where will it
occur?
Where will it
occur?
How will data be
shared?
Guiding T
ools for Instructional Problem Solving – Revised (GTIPS-R)
Example
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
Who is responsible? Who is responsible? Who is responsible? Who is
responsible?
What will be done? What will be done? What will be done? What data will be
collected and how
often?
When will it occur? When will it occur? When will it occur? How will we
decide if the plan is
effective?
Where will it
occur?
Where will it
occur?
How will data be
shared?
Randy
Reading Accuracy
95% Accuracy on grade-level material
76% Accuracy on grade-level material
Randy does
not
self-monitor
while reading
connected
text.
Suzanne – reading
interventionist
Mark – classroom
teacher
Suzanne – reading
interventionist
30 min lessons:
5 min – warm up
(phonics)
20 min – (fluency &
self-monitoring-tappi
ng at word, sentence,
then paragraph level)
5 min –
comprehension
The Intervention
Doc. Worksheet
(IDW) will be used
to record
intervention
sessions
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)
Oral reading
fluency and
accuracy will be
collected on
Friday of each
week using grade
level CBM
probes.
MWF 9:20 to 9:50
10:00 am during
3rd grade planning
time
Directly after every
scheduled
intervention session
3rd grade
intervention room
Suzanne’s
intervention room
The IDW will be shared
at the student data
review meetings
described in Monitoring
Plan column of this
worksheet.
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.
Guiding Tools for Instructional Problem Solving – Revised (GTIPS-R)
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
Poor
1. If Positive:
i. Continue current instructional supports.
ii. Adjust goal upward.
iii. Fade supports.
Comments/Actions:
2. If Questionable:
i. Was intervention/instruction implemented as planned?
Yes
No
ii. If no, what strategies will be utilized to increase implementation?
iii. If yes, should intervention intensity be increased?
Yes
No
Comments/Actions:
Guiding Tools for Instructional Problem Solving – Revised (GTIPS-R)
3. If Poor:
i. Was intervention/instruction implemented as planned?
Yes
No
ii. If no, what strategies will be utilized to increase implementation?
iii. If yes, was instruction/intervention aligned with the verified hypothesis, or is there other
aligned instruction/intervention to consider?
iv. Are there other hypotheses to consider?
v. Was the problem identified correctly?
Comments/Actions:
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Completed 2 March 2021

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