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[District Name] Public Schools
Reading Worksheet
(To document that a student has received appropriate instruction and intervention in reading)
This checklist must be completed for all elementary, middle, and high school students who have been referred to special education
due to a suspected learning disability that affects reading. This information should generally be gathered prior to a referral to special
education as part of early intervention (i.e., alternative procedures required to be implemented in regular education under CT
Special Education Regulations §10-76d-7). (All
boxes must be checked with appropriate documentation provided.)
1. Core General Education Language Arts Instruction (Tier I)
Student has participated in daily general education reading/language arts instruction using scientific research-
based practices provided to the entire class by the general education teacher.
Description of Instruction Provided: General education instruction should involve a comprehensive, district-wide reading
curriculum that addresses state standards and the five areas of reading (e.g., through read-alouds; systematic phonics instruction;
word study and structural analysis; fluency-building activities; explicit vocabulary instruction; literature think-alouds;
comprehension strategy instruction):
2. Small Group/Differentiated Instruction by General Education Teacher (Tier I)
Student has participated in small group, differentiated reading instruction by the classroom teacher as part of Tier I
general education instruction (i.e., for all students). Materials at the student’s instructional level (90-95% word
accuracy and at least 75-80% comprehension) have been used for a minimum of four days per week.
Description –How Core Curriculum was Differentiated to Meet Individual Student Needs in Small Group Setting:
3. Progress Monitoring Assessments (Tier I)
Continuous progress monitoring has been provided to establish a basis for instructional decisions and to document
a student’s response to instruction.
Description/Source of Evidence of Progress Monitoring: Results attached
Assessment
(e.g., curriculum based measurement, curriculum-based
assessments, diagnostic assessments)
Skills/Competencies Targeted
(e.g., phonemic awareness, phonics, fluency,
vocabulary, comprehension)
Dates
4. Supplemental scientific research-based interventions (Tier II – targeted interventions; Tier III - more
targeted and intensive interventions)
Interventions have been implemented based on specific student needs in one or more of the five areas of reading:
phonemic awareness, phonics, fluency, vocabulary, and/or comprehension.
Appropriately qualified and trained staff has provided the interventions, which have been implemented with fidelity
(i.e., delivered in the manner in which they were designed and intended to be used). Documentation indicating
frequency, duration and type of intervention is either listed on this form or attached.