Tier 3 Referral Checklist

(Complete before making a Tier 3 Referral)

Teachers: Please complete the checklist below before referring a student to Tier 3. If you can successfully
answer "Yes" to the *questions below, it is appropriate to continue with the Tier 3 referral.
Student's Name: _________________________________________________________________
___ Yes ___ No

*Has the student participated in a minimum of 2-3 interventions targeted at the

student's specific skill deficit?

___ Yes ___ No

*Has the student received Core curriculum instruction?

___ Yes ___ No

*Has the student attended at least 80% of the scheduled intervention sessions?

___ Yes ___ No

*Do you have 6-8 data points within the student's specific skill deficit to indicate he or
she is not making adequate progress?

___ Yes ___ No

*Is the student performing at or near the 10th percentile or below based on national
norms or at least one grade level below (according to Fountas and Pinnell)?

___ Yes ___ No

*If the student is LEP, the primary cause of their academic difficulties is not a result
of their Limited English Proficiency level.

___ Yes ___ No

If the student is LEP, is the student's progress consistent with other LEP peers?

___ Yes ___ No

Does the student's behavior impede his or her academic performance? If so, answer
the following question.

___ Yes ___ No

Has the student participated in CICO?

Classroom Teacher: ____________________________ Coach Signature: _______________________________ Date: ______

ESL Teacher: ___________________________________ Date: ____________