North Carolina Department of Public Instruction Responsiveness to Instruction/Multi-Tier

System of Supports
School:

Date:

//
Student Name(s)/Grade Level:
Pick One:
Tier I
Tier II
Tier III
Tier II or Tier III only: Has the student had excessive absences/tardies/transience in their school career (if yes, attach relevant
attendance history)?
Yes
No
Student Strengths:

What should our students know and be able to do?

Identify the Problem:

RIOT Review, Interview, Observe, Test

Develop and Test Hypotheses (Why is the problem occurring?)
Instruction:

Curriculum:

Environment:

Learner (Tiers II and III):

Instruction Assessment
Plan/Results:

Curriculum Assessment
Plan/Results:

Environment Assessment
Plan/Results:

Learner Assessment
Plan/Results:

Precise Problem Statement:

Discuss and Select Solutions:

North Carolina Department of Public Instruction Responsiveness to Instruction/Multi-Tier

System of Supports

Develop and Implement Action Plan:

Who?

What?

Where?

Baseline Score:

How will we know students are learning?

Measurement Strategy: Who?

With What?

Data-Based Decision Making Rules: If then

Review Date:

Short Term Goal:

Long Term Goal:
How Often?

How Often?

Think
SMART

North Carolina Department of Public Instruction Responsiveness to Instruction/Multi-Tier

System of Supports
Evaluate and Revise the Plan Date:

How will we respond when

students dont learn?

Results:

How will we respond when

students have already learned?

Next Steps:

Participants (Name and Title):

Parent Involvement in Plan Development:

Conference

Phone Call

Signed letter returned from home

Parent Signature (if applicable): ________________________________________________

Meeting Notes (Optional):

Date:

Other:

North Carolina Department of Public Instruction Responsiveness to Instruction/Multi-Tier

System of Supports
Evaluate and Revise the Plan Date:

How will we respond when

students dont learn?

Results:

How will we respond when

students have already learned?

Next Steps:

Participants (Name and Title):

Parent Involvement in Plan Development:

Conference

Phone Call

Signed letter returned from home

Parent Signature (if applicable): ________________________________________________

Meeting Notes (Optional):

Date:

Other:

North Carolina Department of Public Instruction Responsiveness to Instruction/Multi-Tier

System of Supports
Evaluate and Revise the Plan Date:

How will we respond when

students dont learn?

Results:

How will we respond when

students have already learned?

Next Steps:

Participants (Name and Title):

Parent Involvement in Plan Development:

Conference

Phone Call

Signed letter returned from home

Parent Signature (if applicable): ________________________________________________

Meeting Notes (Optional):

Date:

Other: