This document is a teacher form. It has a column for each level of comprehension and reading standard: general understanding (1) , key details (2), vocabulary structure (4&5), Author's Purpose, Inferences (3&7), Opinions, Arguments, Textual Connections (8&9).
The second column separates questions in three different categories, questions that require words/phrases as answers, questions that require sentences, and questions that require paragraphs.
The third column has all of the reading standards to help guide questions.
The four column is blank so that you can type in your text depending questions.
The fifth column helps to focus every re-visit of the complicated text around a specific skill (general understanding, ect.) that is based on a reading standard. The second column helps break the questions into a variety of complex text-dependent questions.
For a full explanation of how I use this form, please visit my blog: http://freckeled5th.blogspot.com/2014/11/close-reading-text-dependent-question.html