Checklists and Forms


In this section we’ve gathered the RTI planning forms and checklists referenced throughout this site for quick and easy access to help you get started building your RTI framework.

Featured Term

Universal Design for Learning (UDL)

Process of designing instruction that is accessible by all students; UDL includes multiple means of representation, multiple means of expression, and multiple means of engagement; the focus in creation of UDL curricula is on technology and materials.

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The RTI Action Network has developed a new online planning tool to help educators successfully implement RTI K-6. Now available from Corwin Press! >> rti-online-guide
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RTI-Based Specific Learning Disability Determination Worksheet

The RTI-Based SLD Identification Toolkit provides information specifically on an SLD identification process emanating from an RTI service-delivery framework that is in compliance with the specific language of the federal regulations and is informed by the work done to date by several states that have moved to such a process. Rachel Brown, Laura Hauerwas, and Amy Scott developed a worksheet as a sample form for eligibility determination. Download the SLD Worksheet for reference.

Treatment Integrity Protocols

Joseph Kovaleski of Indiana University in Pennsylvania has assembled a collection of available treatment integrity protocols. The protocols have been developed by a variety of sources (publishers, graduate students, practitioners) and no claim is made for their sufficiency or thoroughness but they are made available as an aid to practitioners and researchers until their psychometric qualities can be validated.



The RtI Implementation Rubrics

The Colorado Department of Education (CDE) has developed a set of fidelity tools to improve outcomes for students in Colorado and to support a scaling up of effective practices across the state. The RtI Implementation Rubrics are designed to assist districts, schools, and educators with the implementation of RtI. The tools provide the means to reflect on policies and practices at the classroom, school, and district levels in order to continually improve outcomes for students. These tools are intended to be used statewide and provide needed support in a continuous improvement cycle. The rubrics can also assist districts in their work toward accomplishing their goal of systemic change for increased student achievement (from the CDE's RtI Implementation Rubrics Guidebook, 2010).

Beliefs and Perceptions of RTI Skills Surveys

Self-report surveys have been developed to assess staff beliefs and perceptions that the staff has about their skills in relation to implementation of an RTI model. Download the Beliefs and Perception of Skills surveys to keep on file for your own use.



Self-Assessment of Problem Solving Implementation (SAPSI)

A number of evaluation instruments have been developed both to assess needs for planning purposes and to “progress monitor” RTI implementation. Click on Self-Assessment of Problem Solving Implementation to download one example of this type of instrument.

To learn more about using this form for both planning and evaluation purposes, read Developing a Plan and Evaluating and Refining Implementation.


Determining Our Language of Collaboration Tool

As continued collaboration across diverse situations reveals new areas of confusion or misunderstanding, collaboration teams must revisit their language use and redefine their shared understandings. The tool Determining Our Language of Collaboration can be used to get started.


Intervention Documentation

An intervention implementation log documents three aspects of the intervention integrity: the time (each day) that the student received the intervention, the program or strategy selected for the intervention, and the focus of the intervention. Download the Intervention Documentation to see an example of an intervention documentation form.


Sample RTI Implementation Timetable for Elementary Building

This a chart is a sample of a 3- to 5-year timetable for gradual RTI implementation across reading and math and all the grade levels: Sample RTI Implementation Timetable for Elementary Building. Each school must develop a timetable specific to their individual needs and circumstances.


Checklist of Processes

A checklist of processes that are observable when the school is in the full implementation stage is provided. Schools can use this checklist of characteristics to evaluate whether they are in the full implementation stage, and identify any areas requiring more attention.

Problem Solving and Critical Components Checklists

The degree to which the four major steps in the RTI process (problem identification, problem analysis, intervention, and response to the intervention) are implemented with integrity can be assessed using a Problem Solving Checklist and a Critical Components Checklist. The Problem-Solving Checklist is an observation instrument that is used during problem-solving meetings. The Critical Components Checklist is used to evaluate the degree to which the RTI steps are evidenced in intervention reports.

Data Analysis for Instructional Decision Making: Team Process Script

The Data Analysis for Instructional Decision Making: Team Process Script, which is based on Kovaleski and Pedersen’s (2008) work on best practices in this area, is an outline of the recommended format for DAT meetings. It lists, in chronological order, the items that should be discussed, typical prompts that encourage discussion and decision making, and suggestions for record keeping at each step.

Screening and Information Recording Form

Teams should use the Screeing and Information Recording Form (SIRF) or a similar document to record current student performance, goals, strategies discussed, strategies chosen, students considered for tiered services, and decisions made regarding student placement.

Behavior Screening

Two screening tools to identify students' behavior that could be detrimental in the classroom are provided here: Student Internalizing Behavior Screening Scale (SIBSS) and Student Risk Screening Scale (SRSS). To learn more about using these forms for both screening purposes, read Screening With No Smoke or Mirrors.

School Climate Survey

This survey is designed to get teachers' opinions concerning some aspects of school climate and their attitudes concerning the school, its community and yourself. To learn more about using this survey visit The Center for the Study of School Climate and read Implementing a Combined RTI/PBS Model: Teacher Perceptions.

Sample Story Script

The Story Script is designed to assist educators in sharing student data during a progress monitoring review meeting to ensure they have covered all the essential information and that team members have a collective understanding of the details. To learn more about using this Story Script, read Preparing for a Progress Monitoring Review Process: Engaging in Reflection for Productive Decision Making.