Re-Take Policy

RtI Request Form

Name: ____________________ Hour_________ Date of Request: _________

Request (circle one):

Retake test/quiz: ______________________ Help with ___________________________

Other: ______________________________

Reflection:

Why are you making this request? (example: I didn’t study for the test. I’m confused about….)

If you are taking a retake test, what will you do, in addition to requesting help from the teacher, to improve your test score?

Requested RtI time: _____________________________

Requested retake time: __________________________