Tier II Referral Form

RTI Team Referral FormStudent Name:Current Grade Level:Referral Date:Referring Teacher:1. The student appears to be having difficulty with the following: (Check any thatapply.)□ Reading skills□ Reading strategies□ Reading independently□ Achieving on formal reading assessments□ Achieving on formal and informal reading assessments□ Retaining reading skills and/or strategies□ Behavioral issues□ Attendance/tardiness issues2. Has this student been referred to an RTI Team in the past?□ Yes Date of last referral_______________□ No3. Provide a specific description of the concerns you have for this student. Describethese concerns in observable terms.

6. Assessment DataAssessmentPerformanceAIMSweb LNF Fall___ Winter___ Spring___PSF Fall___ Winter___ Spring___NWF Fall___ Winter___ Spring___ORF Fall___ Winter___ Spring___DRAFall___ Winter___ Spring___WRSD Sight Word AssessmentsFundations (or alternative) AssessmentsWinter___ Spring___WRSD Reading Benchmark ConferenceConferring DataOther