Three-Tier RTI Template (Expanded Version)
Use this page to document a student’s or teacher trainee’s response to instruction and progressively more intensive support. Base decisions on screening, ongoing assessment, observable evidence, collaboration, and student/family voice.
Suggested review cycle: Review progress every 4–6 weeks, or sooner when the evidence indicates that the intervention should be adjusted.
Suggested Capacities properties
| Property | Type | Suggested values / purpose |
|---|---|---|
| Current Tier | Single select | Tier 1 - Core Instruction; Tier 2 - Targeted Intervention; Tier 3 - Intensive Support |
| Intervention Focus | Multi-select | Academic Writing; Research Methodology; Language Proficiency; Engagement/Participation; Behavioral/Social; Other |
| Next Review | Date | Date for reviewing progress and deciding whether to retain, modify, advance, or reduce support |
| Cohort/Seminar | Relation or web link | Connect the record to the relevant program, class, cohort, or seminar |
Student Profile and Initial Identification
**Student / Trainee:****Student ID:****Program / Cohort:****Course / Seminar:****Instructor / Professor:****Date opened:**Next review:
Current tier
-
Tier 1 - Core Instruction
-
Tier 2 - Targeted Intervention
-
Tier 3 - Intensive Support
Area(s) of need
-
Academic Writing
-
Research Methodology
-
Language Proficiency
-
Engagement / Participation
-
Behavioral / Social
-
Other:
Student strengths and assets
Prior knowledge, successful conditions, motivation, relationships, interests, and resources:
Primary concern and observable evidence
Describe what is happening, where it occurs, how often it occurs, and its effect on learning or participation:
Universal screening and baseline data
Record assessment results, work samples, attendance, observations, and other relevant data:
Desired outcome / success criteria
State a specific, measurable, attainable, relevant, and time-bound outcome:
Data sources
RTI team and roles
Student / family voice
Record the student’s perspective, family input when applicable, communication preferences, and agreed priorities:
Tier 1 - Core Instruction
Document how the student responds to high-quality, evidence-based core instruction and universal supports.
Baseline curriculum and instructional context
Course expectations, whole-group routines, and learning conditions relevant to the concern:
UDL alignment / differentiated supports
Which multiple means of engagement, representation, action, and expression are being used? Which appear to be working?
Evidence-based core strategies
Instructional practices used for all learners or embedded in the core course:
Tier 1 goal
**Frequency:****Duration:**Provider:
Tier 1 progress monitoring
| Date | Measure / evidence | Result | Interpretation / next step |
|---|---|---|---|
Tier 1 review decision
-
Continue Tier 1 supports
-
Modify core instruction
-
Move to Tier 2
-
Close the RTI record
Review notes:
Tier 2 - Targeted Intervention
Use this section when a specific gap persists and the student requires supplemental small-group or specialized instruction.
Identified gap
Define the skill, concept, behavior, or performance gap precisely:
Targeted measurable goal
State what improvement is expected, by when, and how it will be measured:
Supplemental intervention plan
Describe the small-group workshop, focused practice, supplementary material, modeling, feedback, or other targeted support:
**Group size:****Provider:****Start date:****Review date:****Frequency / duration:**Setting / location:
Materials / strategies
Tier 2 progress monitoring
| Date | Measure / task | Result | Trend | Instructional adjustment |
|---|---|---|---|---|
Tier 2 review decision
-
Return to Tier 1
-
Continue Tier 2
-
Modify or intensify the intervention
-
Move to Tier 3
Student / family update
Tier 3 - Intensive Support
Use this section for significant hurdles requiring individualized, high-frequency intervention and close collaboration with specialized staff when appropriate.
Summary of prior response
Summarize Tier 1 and Tier 2 supports and the evidence of limited progress:
Intensive need / significant hurdle
State the highest-priority need requiring individualized support:
Individual Action Plan
Record specific measurable goals, one-to-one coaching, high-frequency practice, feedback cycles, and exact next steps:
**Provider / support team:**Frequency / duration:
Access / accommodation supports
Meeting and feedback log
| Date | Participants | Feedback / evidence | Exact next steps |
|---|---|---|---|
Overall RTI Review
Decision
-
Retain the current tier
-
Step down a tier
-
Advance or intensify support
-
Refer for additional evaluation or specialized support
-
Other:
Review summary
Commitments
The student will…
The professor will…
Sign-off
**Student signature / acknowledgement:**Date:
**Professor signature / acknowledgement:**Date:
**RTI team member / specialist:**Date:
Next review:
Workflow tip: Once student records use the Current Tier property, create a Capacities query that surfaces all Tier 2 and Tier 3 records so that targeted and intensive interventions remain visible during the semester.
Updated: A simpler practical version is now available here: https://app.capacities.io/f1711151-3e8c-449c-8203-f47df61f6ea2/ffe000b9-b55f-4209-8fb4-19582c6f16d6 (https://app.capacities.io/f1711151-3e8c-449c-8203-f47df61f6ea2/ffe000b9-b55f-4209-8fb4-19582c6f16d6)