Rti Surveys and forms

Appendix 7: Summary of Tier Placement and Movement

Impact Evaluation of Response to Intervention

Name of School: _______________________________________________ Date: ___________________

Directions: Please complete this form for the 2011-12 school year.

GRADE 1 Name of Benchmark Test: School Year:

Risk Category	Fall	Winter	Spring	Comments
Low Risk
Percent Scoring at or above Criterion
Criterion Score =
Moderate Risk
Percent Scoring at or above Criterion (but below Criterion for Low Risk)
Criterion Score =
High Risk
Percent Scoring at or below Criterion
Criterion Score =
Number of Students Tested

GRADE 2 Name of Benchmark Test: School Year:

Risk Category	Fall	Winter	Spring	Comments
Low Risk
Percent Scoring at or above Criterion
Criterion Score =
Moderate Risk
Percent Scoring at or above Criterion (but below Criterion for Low Risk)
Criterion Score =
High Risk
Percent Scoring at or below Criterion
Criterion Score =
Number of Students Tested

GRADE 3 Name of Benchmark Test: School Year:

Risk Category	Fall	Winter	Spring	Comments
Low Risk
Percent Scoring at or above Criterion
Criterion Score =
Moderate Risk
Percent Scoring at or above Criterion (but below Criterion for Low Risk)
Criterion Score =
High Risk
Percent Scoring at or below Criterion
Criterion Score =
Number of Students Tested

All information gathered for this study will be kept confidential and will only be used for research purposes. The information collected about schools and students for this study will be used only for statistical purposes and may not be disclosed or used, in identifiable form, for any other purpose except as required by law (Public Law 107-279, Section 183).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to this voluntary collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1850-New. The time required to complete this information collection is estimated to average 120 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4537. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Jonathan Jacobson, U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Suite 500J, Washington, D.C. 20208, or email jonathan.jacobson@ed.gov.