MTSS Initial Student Planning Sheet

Resource: Problem Solving Worksheet
Peacekeeper's Email Address
example@example.com
Peacemaker's Name

First NameLast Name
Date

MonthDayYear
Date
School
Team Members
Meeting Purpose
- Step 1: Define the Problem and Set the Goal
  The team will analyze primary data sources to identify problem areas and set a goal.
- 1. What is the benchmark or expected level of performance?
- 2. What is the students' current level of performance?
- 3. What is the comparison peer level of performance (e.g., district, school, national)?
- Conduct a Gap Analysis
- Benchmark and Students
- Benchmark and Peers
- Peers and Students
- Identify the replacement behavior and set a goal (time frame, measure, target population).
- Step 2: Analyze the Problem and Hypothesize
  The team will develop root cause hypotheses using the ICEL by RIOT Framework and activities with secondary data to validate or invalidate hypotheses. Below, record each hypothesis for why the replacement behavior is not occurring, along with its matched prediction statement. Provide any data used to validate or refute each hypothesis, and check Yes to indicate that the data supported the hypothesis or No to indicate that they did not.
  
  Hypothesis: What are the most likely reasons this problem is occurring? Address potential domains of curriculum, instruction, curriculum, environment, and learner.
  
  Prediction Statement: Based upon what ve've learned, what must be changed about the instruction, curriculum, and/or environment in order to enable the student(s) to meet the expectation?
- Hypothesis 1: The problem is occurring because
- Prediction Statement: If ______ would occur, then ______.
- Relevant Supporting Data
- YesNo
- Hypothesis 2: The problem is occurring because
- Hypothesis 2: The problem is occurring because
- Prediction Statement: If ______ would occur, then ______.
- Relevant Supporting Data
- YesNo
- Hypothesis 3: The problem is occurring because
- Hypothesis 3: The problem is occurring because
- Prediction Statement: If ______ would occur, then ______.
- Relevant Supporting Data
- YesNo
- Step 3: Develop and Implement the Plan
  Teams will select the intervention and or strategy that will address the problem and meet the goal. Next, they will develop a plan to implement the strategy.
- Expected outcome of intervention or strategy (see goal from Step 1)
- Verified hypotheses (copy from Step 2)
- Develop an action plan:
- Type option 1Type option 2Type option 3
- Description of Strategy or Intervention
- Implementation:
- Frequency (how often)
- Duration (amount of time)
- When (timeline)
- Who
- Support:
- Who
- How Often
- Description/type
- Data Collection:
- Type
- Frequency
- Review dates performance expectations
- Responsible Party
- Step 4: Evaluate the Plan
- Review date(s).
- Evaluate impact of action plan.
- PositiveQuestionablePoor
- Continue with strategy or intervention.Increase goal.Fade strategy or intervention.Other: Please describe.
- Comments/Actions/Evidence
- Evaluate fidelity of implementation.Continue strategy or intervention.Refine strategy or intervention.Other: Please describe.
- Comments/Actions/Evidence
- 1. Evaluate fidelity of implementation.Evaluate alignment of strategy or intervention with hypothesis.Consider other hypothesis (return to Step 2).Evaluate validity of data.Consider revising problem statement (return to Step 1).Other: Please describe.
- Comments/Actions/Evidence
- Should be Empty:

Conduct a Gap Analysis