<p>I&RS REQUEST FOR ASSISTANCE STRATEGIES AND INTERVENTIONS (Activities completed prior to RFA submission)</p><p>Pupil: Teacher: Date:</p><p>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</p><p>Describe specific academic and/or behavioral strategies utilized in the classroom. What were the outcomes?</p><p>DOCUMENTATION CHECKLIST (Please submit as much of this documentation as possible)</p><p>☐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</p><p>Referrer Signature: Date Submitted: I&RS REQUEST FOR ASSISTANCE STRATEGIES AND INTERVENTIONS Pg. 2</p><p>FOR SST USE ONLY:</p><p>I&RS/504 Coordinator: ______Date RFA Received______</p><p>☐RFA Accepted ☐RFA Returned Reason for Returning RFA</p><p>Class-wide Recommendations (if returning RFA)</p>