Rti Surveys and forms

Appendix 4: Recording Form for Decisions Based on Reading Fall Screening/Benchmark

Instructions:

1. Please complete a separate form for each grade (1-3).

2. For each student, please indicate whether the student was assigned a reading intervention resulting from the fall screening/benchmark.

3. Please record the score each student in the grade level received on the screening measure(s) that your school employed to identify students requiring a reading intervention.

4. Note: Some schools use one screening/benchmark measure; other schools collect multiple screening measures. We provide columns for up to four measures.

5. In the table below, please name the screening/benchmark measure and give the date that it was administered.

Circle Grade Level of Students on this form: 1 2 3

Screening/Benchmarking Measure(s)	Name of Screening/Benchmarking Test	Date of Administration
Measure 1:
Measure 2:
Measure 3:
Measure 4:

Student	Score on Measure 1	Score on Measure 2	Score on Measure 3	Score on Measure 4	Instructional Decision
					Tier 1	Tier 2	Tier 3	Special Education

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 10 hours 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.