Strategies and Interventions

I&RS REQUEST FOR ASSISTANCE STRATEGIES AND INTERVENTIONS (Activities completed prior to RFA submission)

Pupil: Teacher: Date:

In School Resources Date(s) Outcome(s) Implemente d Duration ☐Reading Recovery/Read 180/Wilson Reading/Waterford Early Reading Program ☐Social Worker ☐Tutoring before/after school ☐Conference with Vice Principal ☐Conference with Literacy Coach/LAL Teacher ☐Conference with Math Coach/Math Teacher ☐Conference with I&RS Coordinator ☐Conference with Parent/Guardian ☐Conference with School Counselor ☐Conference with School Nurse ☐Assistance from Aide ☐Other

Describe specific academic and/or behavioral strategies utilized in the classroom. What were the outcomes?

DOCUMENTATION CHECKLIST (Please submit as much of this documentation as possible)

☐Copy of Cum Card with most recent Standardized Test ☐Sample of class work, test scores, literacy logs, math Scores logs & science logs ☐District & Curriculum Assessments (DRA, Slossan, SPA, ☐Disciplinary records (suspensions, SOS) Brigance etc.) ☐Attendance Records (763, s) ☐Copy of Current Report Card ☐Documented interventions by literacy coaches and math ☐Teacher Documentation of Parent contact & dates tutors ☐Documentation of behavioral intervention implemented

Referrer Signature: Date Submitted: I&RS REQUEST FOR ASSISTANCE STRATEGIES AND INTERVENTIONS Pg. 2

FOR SST USE ONLY:

I&RS/504 Coordinator: ______Date RFA Received______

☐RFA Accepted ☐RFA Returned Reason for Returning RFA

Class-wide Recommendations (if returning RFA)