Academic Referral for Standard Tier III Intervention (K-8)

This form will not be used for students who scored in the bottom 5% on the universal screener and who are being screened for dyslexia specific intervention. For those students, we will follow the Dyslexia Specific Intervention Pathway.

This form is intended for use in Grades K-8.

Student First Name *

Student Last Name *

Student State ID Number *

Grade *

Referrer First Name *

Referrer Last Name *

Referrer Email Address *

School *

A student should be referred to the RTI Team for consideration for placement in standard Tier III intervention if he/she:

Grades K - 2 - meets TWO of the following criteria

Grades 3 - 8 - meets THREE of the following criteria

Scores Intensive on DIBELS (grades K-3)

Scored In Need of Support on Legacy Data (Scantron, Lexia, Dreambox, ASPIRE Reading or Math (grades 4-5))

Scores 2 grade levels below on the ISIP Reading test

Scores 2 grade levels or below on the ISIP Math test

Scores 2 grade levels or below on the i-Ready Reading Assessment.

Scores 2 grade levels or below on the i-Ready Math Assessment

Retained in grade from previous year

Scores a 59 or below in any core subject as identified on the end of the year report card from the previous grade level

Teacher recommended based on classroom performance

If a student meets these requirements, please complete the designated section of the Intervention Plan for Grades K-8.