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Euclid City Schools

Response to Intervention- Elementary Form (Tutors) TIER 2

Student Name: Grade DOB

Teacher Name: Start Date


Check the area(s) of concern:

¨ Reading Comprehension ¨ Articulation ¨ Math Calculation


¨ Reading Fluency ¨ Listening Comprehension ¨ Math Reasoning
¨ Reading Skills ¨ Oral Expression ¨ Behavior
¨ Other______________ ¨ Written Expression

Background History (note relevant information/assessment data):

Statement of Concern (see examples):

Goal:
¨ To reach grade level.
¨ Other:____________________________________________________________

Intervention Name Weeks 1-9


Intensity
Frequency (X/week) Duration from to
(minutes/day)
0- Nothing happened
Week 1 Week 4 Week 7 (teacher/student
absence, change of
Week 2 Week 5 Week 8 schedule, etc.)
1- Minimal engagement
Week 3 Week 6 Week 9 2 - Engaged
 

Intervention Name Weeks 10-18


Intensity
Frequency (X/week) Duration from to
(minutes/day)
Week 0- Nothing happened
Week 13 Week 16
10 (teacher/student
Week absence, change of
Week 14 Week 17 schedule, etc.)
11
1- Minimal engagement
Week
Week 15 Week 18 2 - Engaged
12
 
Attach additional documentation.

Refer to Tier 3: Date:

Revision  Date:  September  2013