182 REPRODUCIBLE
How RTI Works in Secondary Schools • © 2012 Solution Tree Press • solution-tree.com
Visit go.solution-tree.com/rti to download this page.
Problem-Solving Team Intervention Form
Use this form to articulate the measurable, observable goal for the student, the specic details of the
intervention to be implemented, and the progress monitoring of that intervention. Problem-solving teams
should complete each piece of information to promote delity of implementation of the both intervention
and progress monitoring. Finally, teams will need to document what criteria will be used to determine if
the student is responding to the intervention and indicate when the team will review student progress.
School or District:
Student: Plan Development Date:
Intervention #: 1 2 3
Area of concern: Reading Math Writing Behavior
Goal:
INTERVENTION
Brief description:
Description of needed materials:
Intervention implementer:
When:
Where:
How often:
MEASUREMENT SYSTEM
Data-collection system:
Data collector:
What will be recorded?
Frequency of data collection:
When will data be collected?
DECISION-MAKING RULE
Slope/trend analysis Consecutive data-point rule
Level of performance Other:
Intervention Start Date: Review Date: Time: Place:
