(School or District Name Here)
Student Intervention Plan
Student Name:______
Start Date: ______
Student Service Results (Indicate One
q 1. Successfully exited intervention
q 2. Exited to another intervention
q 3. Continue in Intervention
q 4. Moved from school
q 5. Graduated-Did not meet goals
q 6. Other______
Tier Status (Indicate One)
q Tier 1 (leave blank)
q Tier 2 q Tier 3
Intervention Type (Indicate One)
q Course q ESS
q MAF q RTA
q Other______
q Acceleration q Credit Recovery
Intervention Content Areas (Circle)
q Reading q Writing
q Reading/Writing (combined)
q Math q Behavior
q Science (Optional)
q Social Studies (Optional)
q Other (Explain below)
______
Intervention Materials 1
q Teacher Developed Intervention Lesson
q KDE Transitional
q Post-Secondary Transitional
q Vendor Program (Program Code_____)
q Vendor Provided Service
q Other______
Intervention Staff
q Certified q Peer Tutor
q Classified q Computer Based
q Volunteer q Other ______
Student Grade:______
End Date: ______
Total Hours Served: ______
Delivery Location(Indicate One)
q On Site q Off Site
Delivery Method (Indicate One)
q In Person q Blended
q Online
q Other Delivery Method (Explain below):
______
Frequency (Indicate One)
q Daily q Weekly
q 2 days/week q Twice Monthly
q 3-4 days/week
q Other Frequency:
______
Duration (Indicate One)
q < 30 minutes q 60 minutes
q 30 minutes q > 60 minutes
q 45 minutes
The following fields are optional for KDE but may be required by your district
Funding Source (Indicate One)
q General Fund q IDEA
q 21st CCLC q Other
q Title I
Select all skill areas that apply
q Literacy Readiness q Reading Fluency
q Reading Vocabulary q Reading Phonics
q Reading Comprehension
q Writing Mechanics q Hand Writing
q Writing Content q Math Reasoning
q Math Computation q Measurement
q Math Number Sense
q Math Numeracy Readiness
q Geometry q Algebraic Thinking
q Probability/Statistics q Behavior
q Social/Emotional q Cognitive
q Language q Adaptive Skills
q Acceleration q Credit Recovery
q Content Other
Parental Involvement
q Parent Notified of Intervention Plan
q Included in Planning
q Provided Parent with Resources
q Parent Attended Intervention Meeting
q Parent Provided w/ Student’s Data
Referred
q Eye Exam
q Medical Exam
q Dental Exam
q FRYSC
q Other (Explain below):
______
Comments: