IF00 Response to Intervention - Collaborative Assistance Team (Tier I) Data Sheet

RESPONSE to INTERVENTION PROCESS - COLLABORATIVE ASSISTANCE TEAM (Tier I) DATA SHEET

Title

Name of Student *

Date of Birth (mm/dd/yyyy) *

Grade *

Teacher *

Date of Initial Meeting (mm/dd/yyyy) *

I. Behavior/Skill of Concern (pick one or two per content area; e.g., 1 reading, 1 math, 1 behavior) *

II. Baseline Data

a.) *

b.) *

c.) *

III. Measurable Data

What do you want the student to be able to do after 6 weeks of intervention?

a.) GOAL 1: *

b.) GOAL 2: *

c.) GOAL 3: *

IV. Interventions

List one or two interventions for each goal that will be implemented (see content area Intervention Sheet and attach to this form). Please indicate how you will collect data.

Interventions for GOAL 1: *

Interventions for GOAL 2: *

Interventions for GOAL 3: *

V. Follow-up CAT meeting

Outcome data for GOAL 1: *

Outcome data for GOAL 2: *

Outcome data for GOAL 3: *

VI. CAT Team Decision *
interventions were successful; student no longer needs CAT
student has made progress; continue same interventions
add/change interventions & continue in CAT
student did not make progess; more intensive interventions needed refer to IAT (Tier II)

If add/change interventions & continue in CAT, explain (if not applicable type NA) *