Rti Surveys and forms

Appendix 5: Rosters of Students and Data on Reading Service Placement

School Name:
Year:
First Day of School:
Last Day of School:
Benchmark 1 Date:
Benchmark 2 Date:
Benchmark 3 Date:

Directions: Please complete this form for all students who received tiered instruction beyond core reading.

Student Name	Grade	Placement at Beginning of Year (e.g.,Tier-1)	Date of 1st Tier change	Student’s Tier after 1st change	Date of 2nd Tier change	Student’s Tier after 2nd change	Date of 3rd Tier change	Student’s Tier after 3rd change	Date of 4th Tier change	Student’s Tier after 4th change

All information gathered for this study will be kept confidential and will only be used for research purposes. The information collected about schools and students for this study will be used only for statistical purposes and may not be disclosed or used, in identifiable form, for any other purpose except as required by law (Public Law 107-279, Section 183).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to this voluntary collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1850-New. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4537. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Jonathan Jacobson, U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Suite 500J, Washington, D.C. 20208, or email [email protected].