Response to Intervention Assessment Questionnaire
Complete this form to evaluate a learner’s support needs through the RTI process. Please answer all items based on your observations and professional judgment.
Learner's Full Name
*
First Name
Last Name
Grade Level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Area(s) of Concern
*
Reading
Mathematics
Writing
Behavior
Attention/Focus
Social Skills
Other
How frequently do the concerns occur?
*
Rarely
Sometimes
Often
Very Often
Severity of the concerns
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Please rate the learner’s response to previous interventions
*
1
2
3
4
5
Which intervention strategies have been tried?
*
Small group instruction
One-on-one support
Behavioral supports
Peer tutoring
Classroom accommodations
Other
Intervention Effectiveness Matrix
*
Rows
Not Effective
Somewhat Effective
Highly Effective
Small group instruction
1
2
3
One-on-one support
4
5
6
Behavioral supports
7
8
9
Peer tutoring
10
11
12
Classroom accommodations
13
14
15
Describe any additional observations or context (optional)
Suggested next steps for the learner
*
Continue current interventions
Increase intervention intensity
Refer for further evaluation
Other
Submit Assessment
Should be Empty: