Baseline and Planning Form

Student Name
Date referred_____
Steps 1 List 2 key issues from Strengths & Concerns form:

Referring person(s)

Step 2
Academic
Behavior/Executive
function_
Baseline for 2 key issues:
Gap from typical student:
Places problem is observed:
Times when problem is observed
Things that trigger the problem:
__________________________________________________________________________________ __
Strategies that resulted in positive response
Strategies found to be ineffective
______________________________________________________________________________________
Rewards & punishments found to be effective:
Rewards & punishments not recommended:
Step 3 D What will teacher do differently?
A Student will achieve what?
T Timeframe?
A How we will assess growth?
_________________________
Step
Step
Step
Step

4
5
6
7

Team members:
Who will contact parents?
Who will make the follow-up call?
Who will prepare the student?
Referral taken by:

*Attach

Strengths and Concerns form

**make a copy for Principal, teacher, and RTI Coach