Tier 1 Documentation of Differentiation
Student Referral to RTI2 TeamStudent Name: _______________________ Birthdate: _____________ Age: ________ School: ___________________Teacher: _____________________ Grade: __________Parents/Guardian: _____________________________ Contact info: ________________Student’s Current PerformanceTarget area Benchmark score√ if below 25th percentileReadingPhonological Awareness Phonics Reading Fluency Reading Comprehension VocabularyMathMath ComputationMath Problem SolvingWritten ExpressionWriting**For the earliest skill area checked, please attach the corresponding page of differentiation strategiesInformal/Additional AssessmentsScoreStudent’s Instructional reading level (i.e. DRA, lexile)Student’s Independent reading level (i.e. DRA, lexile)Other (please specify)Other (please specify)Special Education/Program Interventions:□ ESL□ Counseling□ Other: _______________□ Speech/Language□ Tutoring/ Reading ClubClassroom Accommodations (If appropriate)Check those that apply (max 3 at a time)General classroom AccommodationsDate startedDate(s) reviewedNotes/Observations (optional)Small group reading instruction at ability levelSmall group math instruction at ability levelPreferential seatingDirections given in short, clear, stepsDirections repeated frequentlyVerbal/non-verbal prompts, cuesDirections repeated by studentPair up with another student for assistanceAllow ample response timeFrequent reviewVisual aidsUse of manipulativesAssignments and/or tests read aloudOral assessmentsModified/shortened assignmentsDaily/weekly behavior planOther:Other:Check those that apply (max 3 at a time)Letter NamingstrategiesDate startedDate(s) reviewedNotes/Observations (Optional)Match lower case lettersMatch upper case lettersMatch upper case to lower case lettersFind letters in textPlay Memory Game with letter cardsPractice sorting lettersPractice ordering lettersOther:Other:Check those that apply (max 3 at a time)Letter SoundstrategiesDate startedDate(s) reviewedNotes/Observations (Optional)Practice matching letters to their corresponding soundPlay Memory game to match letter to soundSort pictures by their initial phonemePractice matching final phonemes to their corresponding letterPractice sorting pictures by final phonemeMatch medial phoneme to corresponding letterOther:Other:Check those that apply (max 3 at a time)Phonological Awareness strategiesDate startedDate(s) reviewedNotes/Observations (Optional)Practice recognizing words that rhymeIdentify/match rhyming picturesCreate silly sentences with alliterationUse counters or magnets to sound out words (e.g. Elkonian boxes)Practice clapping syllablesUse word families (e.g. –at, -in) to form rimesPlay games to identify words that have the same beginning, middle, and ending soundsOther:Other:Check those that apply (max 3 at a time)PhonicsstrategiesDate startedDate(s) reviewedNotes/Observations (Optional)Practice matching letters to their soundsGroup words by common spelling patternsUse plastic letters to make words by changing beginning letterSort words by initial or ending consonant soundsHighlight words parts, suffixes, or prefixesTeach syllable patterns. Students divide words into syllablesForm words without medial vowel sound (e.g. p_t). Students supply missing letter to form different wordsOther:Other:Check those that apply (max 3 at a time)FluencystrategiesDate startedDate(s) reviewedNotes/Observations (Optional)Guided oral reading at student’s independent reading levelSilent reading at student’s independent reading levelHave student follow along with book on tapeUse of tracker (i.e. index card) to keep place while readingChoral reading. Teacher sets the pace and models aspects of reading fluencyUse flashcards to practice sight words and/or commonly misread wordsRepeated reading passages at student’s instructional level.Other:Other:Check those that apply (max 3 at a time)VocabularystrategiesDate startedDate(s) reviewedNotes/Observations (Optional)Post and interact with high frequency words on a word wallCollect high frequency words in a personal vocabulary journalUse of graphic organizersCreate a vocabulary semantic web or mapMatch vocabulary words with their meaningsSort words into groups using the same root or baseUse analogiesOther:Other:Check those that apply (max 3 at a time)Reading ComprehensionstrategiesDate startedDate(s) reviewedNotes/Observations (Optional)Access prior knowledge by discussing book/passage before readingMatch sentence and picture cardsBreak long passages into shorter reading segments and have students recall information from each segmentCompare characters using Venn diagramsUse advance, semantic, and graphic organizersRetell stories using puppets or actorsUse time lines to recall events in story.Other:Other:Math StrategiesCheck those that apply (max 3 at a time)Math Computation StrategiesDate startedDate(s) reviewedNotes/Observations (Optional)Separate basic addition and subtraction facts into “sets”. Require the student to memorize each set in succession.Choose a peer to drill the student each day on math facts (e.g. flash cards)Have student complete math facts worksheet and use a calculator to check and correct answersUse manipulatives to represent quantities in math problemsDevelop math reference sheet for the student to keep at his/her desk (e.g. steps used in doing addition, subtraction, multiplication, division problems)Provide student with a number line on his/her desk to use as referenceRequire student to go through math assignments and highlight or otherwise mark operation of each problem.Other:Other:Check those that apply (max 3 at a time)Math Problem Solving StrategiesDate startedDate(s) reviewedNotes/Observations (Optional)Teach the student clue or key words to look for in word problems that indicate mathematical operationsHave the student verbally analyze the steps that are required to solve word problemsHave student write a number sentence after reading a math word problem.Have student highlight key words that represent mathematical processes (e.g. all together, difference, etc)Provide student a list of words and phrases that often indicate certain mathematical processes (e.g. between, how many more/less, etc)Have student solve word problems by manipulating objects.Allow student to use calculator when solving math problems.Other:Other:Writing StrategiesCheck those that apply (max 3 at a time)Written Expression StrategiesDate startedDate(s) reviewedNotes/Observations (Optional)Provide student a model of correctly written material.Allow student to perform a “practice page” before turning in the actual assignment.Assign the student shorter tasks while increasing the quality of expectations.Provide exercises for making sentences out of non-sentence groups of words.Give the student a group of unrelated words (e.g. author, read, love, etc) and have him/her make up a paragraph including all the words)Provide the student with 5 or 6 sentences out of sequence. Have student cut them out and paste in proper order.Use graphic organizers to help student organize writing activitiesOther:Other: ................
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