This form is used to refer students to tier 2 of RTI. It can be used in conjunction with my RTI benchmark assessments, or can be used based off of the benchmark your school uses.
The teacher would fill out the baseline data with the scores in which the student is struggling and goal score would be set. For example, in my school we record the scores that are below 65% then would set a goal score of 80%. The teacher then uses this data to target instruction on the most foundational skills until student reaches their goal. Once the student has met their goals in all areas they are struggling, the student may be referred back to tier 1.