MTSS/RTI Problem-Solving Team Note

Student Name: [Student full name]

DOB: [DOB (MM/DD/YYYY)] Grade: [Grade] School: [School name]

Student ID: [Student ID]

Primary Language: [Primary language] Interpreter Used: [Yes / No / Unknown/Not provided]

Program Status: [General education / Multilingual learner / 504 / IEP / Other: specify]

Meeting Date: [Date (MM/DD/YYYY)] Start/End Time: [Start time–End time]

Meeting Type: [Initial problem-solving / Follow-up data review / Intervention change / Referral discussion] Tier Focus: [Tier 1 / Tier 2 / Tier 3 / Not applicable]

Participants

Name	Role	Present (Y/N)
[Name]	Facilitator	[Y / N]
[Name]	Minute Taker	[Y / N]
[Name]	Classroom Teacher	[Y / N]
[Name]	Interventionist	[Y / N]
[Name]	School Psychologist/Counselor	[Y / N]
[Name]	Administrator	[Y / N]
[Name]	Parent/Guardian	[Y / N]
[Name]	Student	[Y / N]
[Name]	[Other role]	[Y / N]

[How required role absences were addressed, if applicable] (Add or remove rows as needed. Include only if a required team member was absent.)

Referral Question

[Referral source and neutral reason in one sentence]

[Testable referral question framing what the team will address with data and planning]

Strengths: [1–3 concrete strengths, interests, or conditions under which the student succeeds]

Problem-Solving Cycle 1

(Duplicate this Problem-Solving Cycle section for each distinct student concern addressed.)

Problem Definition

[Operationalized problem statement: who is impacted; what observable skill/behavior occurs vs. expected; when/where it occurs; current rate/level with measurement. Do not include hypothesized causes.]

Baseline: [Value, measure, date range] Benchmark/Expected: [Target value and source] Gap: [Quantified discrepancy]

Prior Interventions: [Brief summary including duration, observed response, and any fidelity concerns]

Data Collection Plan: [Measure, responsible party, start date, target completion date] (Include only if baseline data do not yet exist.)

Data Reviewed

• [Data source, date(s): Brief summary of decision-relevant information]
• [Data source, date(s): Brief summary]
• [Data source, date(s): Brief summary]

Data Quality Considerations: [Missing data, atypical conditions, or measurement limitations affecting interpretation] (State "None noted" if applicable.)

Hypotheses

• [If (barrier/condition), then (problem) occurs because (mechanism), supported by (specific data).]
• [If (barrier/condition), then (problem) occurs because (mechanism), supported by (specific data).]

Exclusionary Considerations Reviewed: [Opportunity to learn, attendance, language access, implementation consistency, medical factors] (Include for decisions that may lead to intensification or referral.)

(If hypotheses are unchanged from a prior meeting, state: "Hypotheses unchanged; see note dated [date].")

Intervention Plan

(Repeat this subsection for each intervention; document "Intervention continued as designed; see note dated [date]" if no changes.)

Intervention: [Name/approach] Target Skill/Behavior: [Specific skill/behavior targeted]

Rationale: [Brief evidence-informed justification linked to hypothesis]

Provider: [Name and role] Group Size: [Number of students]

Frequency/Duration: [Sessions per week, minutes per session] Total Planned Duration: [Weeks until review]

Setting: [Location/context] Start Date: [Start date]

Materials/Program: [Program/materials to be used]

Make-up Procedures: [How missed sessions will be made up]

Supports Needed: [Accommodations, language supports, staff training/coaching] (Include only if applicable.)

Fidelity Plan

Method: [Observation checklist / Self-report / Coaching log / Other] Who: [Person responsible] Frequency: [How often checks occur]

Acceptable Fidelity Threshold: [Quantified criterion] Plan if Fidelity is Low: [Support plan and re-check timeline]

(Required for Tier 2/3 interventions and plans supporting high-stakes decisions.)

Progress Monitoring Plan

Measure: [Specific tool and construct measured]

Baseline: [Value] Goal: [Target value] Goal Date: [Date]

Frequency: [How often data are collected] Collector: [Who collects and graphs]

Data Location: [Where data are stored/graphed] Review Cadence: [When team reviews data]

Goal Logic: [Aimline or growth calculation used] (Include if applicable.)

Decision Rules

• Continue: [If-then criteria indicating adequate progress]
• Modify/Intensify: [If-then criteria indicating inadequate progress and planned changes]
• Fade/Exit: [If-then criteria indicating sustained success]
• Referral for Evaluation: [If-then criteria for considering formal evaluation] (Note: RTI/MTSS cannot delay evaluation if disability is suspected; parent may request evaluation at any time.)

Minimum Data Points Required: [Number and time span] Analysis Method: [Trend line / Median rule / Points below aimline / Other]

Next Steps

Next Meeting Date: [Date] Interim Check-in Plan: [Who will check what, when, and how]

Family Communication

[Summary of what was communicated to family: concern, plan, and monitoring; how/when progress updates will be provided; language supports used/needed]

[Outreach attempts and next steps if family was invited but not present] (Include only if applicable.)

Student Involvement: [Student-friendly goal and self-monitoring/reinforcement components] (Include only if age-appropriate and applicable.)

Action Items

Action	Owner	Due Date
[Task description]	[Name/Role]	[MM/DD/YYYY]
[Task description]	[Name/Role]	[MM/DD/YYYY]

Attachments

• [Document label, date]
• [Document label, date]

Documentation

Note Author: [Name and role]

Attestation: This note reflects team decisions made during the meeting.

(Omit sections not discussed or not applicable to this meeting type. For required fields where data are unknown, use "Unknown/Not provided." Maintain clear separation between facts/data, hypotheses/interpretations, and decisions/plans.)