Response to Intervention (RTI) Awareness Survey
By Mrs. Brenda Hicks Williams
Section 1: Demographic Information
Instructions: Place a mark (X) next to the appropriate item. Choose only one answer.
A. What is your job title?
1. ) Principal/Assist. Principal
4. ) Social Worker
7. ) Special Ed. Teacher
2. ) School Nurse
5. ) Counselor
8. ) Gen. Ed. Teacher
3. ) School Psychologist
6. ) Speech Pathologist
9. ) Other
B. How many years in this position?
10. ) 1-5 11. ) 6-10 12. ) 11-15 13. ) 16-20 14. ) 21-25+
Section 2: Response to intervention participation
Instructions: Place a number (1, 2, 3, or 4) in front of each item to indicate how significate you think each item is to RTI implementation.
1 = I do not know 2 = Not significant 3 = Somewhat significant 4 = Very significant
16. ) Parent participation
15. ) Teacher participation
17. ) Student observations for intervention decisions
18. ) Data collection to monitor student progress
19. ) Professional development to learn RTI procedures
Section 3: Response to intervention procedures
Instructions: Place a number (1, 2, 3, or 4) in front of each item to indicate who you think is responsible for each procedure.
1 = Teacher or Parent 2 = Teacher or RTI Specialists 3 = RTI Specialists 4 = All
21. ) Refer student to RTI Committee
20. ) Get extra help for student
22. ) Observe students and implement interventions
23. ) Administer diagnostic assessments to students
24. ) Contact parent for permission to administer diagnostic assessments
25. ) Maintain data collection to monitor student progress