BREATHITT COUNTY INTERVENTION SERVICES PLAN

GRADES 6-12

Student Name: ______Beginning Date: ______Review Date: ______

Grade: ______DOB: ______

ENGLISH / MATH / READING / SCIENCE
Benchmk / Score / Benchmk / Score / Benchmk / Score / Benchmk / Score
EXPLORE (8th Grade) / 13 / 17 / 15 / 20
PLAN (9th Grade) / 15 / 19 / 17 / 21
PLAN (10th Grade) / 15 / 19 / 17 / 21
ACT (11th Grade) / 18 / 19 (21) / 20 (22) / 24
COMPASS
FALL / SPRING / FALL / SPRING
GRAY ORAL / Other
GRAY SILENT / Other
K-PREP (CRT/NRT)
Grade Level / Reading / Math / Science / Social Studies / Writing (KCAS)
6
7
8
END-OF-COURSE
English II / Algebra II / Biology / Am. History
9
10
11
12
Grade Level / THINKLINK / STAR
Math / Reading / Science / S.S. / Fall / Spring
A / B / C / A / B / C / A / B / C / A / B / C
6
7
8
9
10
11
12
Assessment Notes:

Detailed Explanation of Interventions

RtI Plan

Subject / Specific skills to be addressed: / Strategies to be used: / Research-Based Program/materials:

ESS Plan Before School: ____ After School: ____ Daytime: ____ Summer Program: _____

Subject / Specific skills to be addressed: / Strategies to be used: / Research-Based Program/materials:

Behavioral Plan

Subject / Specific skills to be addressed: / Strategies to be used: / Research-Based Program/materials:
Grade Level / Number of Absences
1st Semester / Number of Absences
2nd Semester / Classroom Performance
(Teacher comments)
6
7
8
9
10
11
12

Behavioral Plan

Student's Name: ______Teacher Name: ______
Date: ______

Please rate each behavior listed.

1 2 3 4 5 6 7 8 9

Never/Seldom Sometimes Usually/Always

I.  General Classroom Behaviors / Strategies to Address Behavior
Gets along with others while showing socially appropriate behaviors.
Completes class assignments on time, applying his/her best effort.
Speaks respectfully and complies with adult requests without argument or complaint.
Remains focused on the teachers or the assignment during class or work periods.
II. Physical Aggression
Treats others appropriately, and does not bully, threaten, or intimidate them.
Avoids engaging in rough, physical ‘horse-play’ with other students.
Keeps hands to him/herself, not touching classmates without permission.
Refrains from making physical threats against other students.
Treats the property of other students with care and respect.
Gets along with others while showing socially appropriate behavior.
Avoids getting involved in physical fights.
Interacts with others without threatening the physical safety of self or others.
III.  Verbal Behaviors
Speaks respectfully and complies with adult requests without argument or complaint.
Is respectful of other students’ feelings and avoids teasing them.
Takes responsibility for hi/her own mistakes or misbehaviors and does not attempt to shift blame.
Is quiet during work or study periods, and does not make noise or call out.
Waits to be called on or given permission to speak before talking.
Uses only appropriate language in all settings, and does not swear.
Waits his/her turn in discussions, and does not interrupt others.
IV.  Inattentive/Hyperactive Behaviors
Focuses attention on teacher instructions, classroom lessons, and assigned work.
Thinks about the consequences of his/her actions before acting.
Sits in class without fidgeting or squirming more than peers.
Remembers academic instructions and directions without needing extra reminders.
V.  Socially Withdrawn Behaviors
Shows appropriate dependence in the classroom and did not cling to adults.
Appears relaxed, with little sign of anxiety/fear of being in school.
Is spontaneously included by peers in group work/play situations.
VI.  School Work-Related Behaviors
Is motivated to work on class assignments/projects.
Takes care with school assignments, avoiding careless errors.
Completes assigned classwork and homework.
Other

Wright, Jim. Classroom Behavior Report Card Resource Book. <http://www.interventioncentral.org>

If the child is on medication, please answer the following questions:


Can you tell when the child is on medication or not? ______


Does the medication work consistently throughout the day? ______


Does the child appear to be on too much or too little medication? ______

Administrator Signature / Date / Comments:
Teacher(s) Signature / Date / Comments:
Parent Signature / Date / Comments:

Per KRS 158, 6453, KRS 158.6459, KRS 158.649, KRS 158.792, KRS 164.0207, KRS 158, 844, KRS 158.441, KRS 070, 704 KAR 3:305