Response to Instruction & Intervention Tier III Intervention Success Plan

School: / Student’s Name:

TST Committee Meeting Date: / / .

Month Day Year

Tier III Intervention Implementation Date (Projected when support will begin): / / .

Month Day Year

MSIS Number: Grade: Date of Birth: / / . Age:

Month Day Year

Ethnicity: Gender: Female Male

Parent/Guardian Name: Parent/Guardian Name:

Address:

Phone Number: Email:

TST COMMITTEE PARTICIPANTS
Initial Tier III Intervention Revised Tier III Intervention
Name / Position / Name / Position
Principal / Interventionist
Parent / Counselor
Students Strengths, Preferences, and Interests
Identify the student’s educational and/or behavioral strengths, interest areas, significant personal attributes and personal accomplishments as indicated by formal or informal assessment. Identify the skills or behaviors the student has mastered. Be sure to include specific feedback from the student.
Educational Behavioral Strengths
Interest areas
Personal Attributes
Personal Accomplishments / List data sources relative to describing the student’s strengths, preferences and interests (e.g. interviews, formal assessments, informal assessments etc.).
Impact of Difficulties and Student Needs (Critical Skills and Behaviors or Developmentally Appropriate Activities)
Describe the effects of the student’s significant difficulties on involvement and progress in the general education curriculum, including the impact on the student’s current level of functioning in reading, math, and behavior, and the functional implications of the student’s skills. / List data sources relative to describing the student’s needs and impact of his/her significant difficulties (e.g. progress monitoring, observations, assessments, etc.).
Parent/Student Input
Include any concerns of the parent and, as appropriate, the student for enhancing the education of the student.
CURRENT LEVELS OF ACADEMIC AND BEHAVIORAL PERFORMANCE
Present Levels of Academic Performance Summary: Reading Math
Present Levels of Behavioral Performance Summary: Social Emotional Behavioral
Include results of the initial or most recent evaluation, including, if appropriate, the results of any universal screening, interventions, progress monitoring and gap analyses.
Results / Data Source / Date
Does this area impact the student’s academic achievement? Yes No
Does this area impact the student’s behavioral performance? Yes No
MEASURABLE LONG RANGE GOAL
Goal # / Measurable Long Range Goal / Measure
1
Obj. # / Short-Term Instructional Objectives/Benchmarks
1.1
1.2
1.3
1.4
1.5
Details of Intervention
Describe supplemental and/or small group strategies utilized – should be backed by scientifically-based research (SRB)
Provide specific evaluation criteria, in measurable terms, utilized to determine effectiveness and monitor progress. / Frequency and duration (time) of interventions
Name(s) and role(s) of individual(s) responsible for delivering intervention(s). / Name / Role/Responsibility
Parental Notification: / Student’s parent(s) notified of Tier III intervention (check one): Yes No
Date and method of notification: / Conference Phone Conference Mail
Report of Progress
Methods of Measurement / Progress on Long Range Goal
OBS = Observation
CRT = Criterion-Referenced Test
CBM = Curriculum-Based Measure
WS = Work Samples
D/P = Demonstration/Performance
Other: / A. The student is making sufficient progress to meet the long-range goal.
B. The student is making insufficient progress to meet the long-range goal. (A TST meeting must be held to discuss revisions.)
C. The long-range goal has been met or exceeded.
D. This long-range goal has not been introduced yet.
Date of Report / Current Level of Performance for Report of Progress
Describe the student’s current performance on the long-range goal based on progress on short-term objectives/benchmarks using the identified method of measurement (OBS, CRT, CBM, WS, D/P, etc.).
**Attach Data Source/Provide Parents with Data Summary / Progress Code
Notification of Progress Provided to Parents/Guardians
Type / Progress Notes / Report Cards / Goals Sheets / Other
Frequency / Every 4 ½ weeks / Every 6 weeks / Every 9 Weeks / Other
Integrity Checks for Tier III Intervention(s)
Instructions: School administrators, check the box next to each trait of quality implementation demonstrated during observation. Complete at least two (2) integrity checks at equal intervals during course of intervention.
Integrity Check #1 / Date: / Integrity Check #2 / Date:
The intervention is described in specific, measurable terms that can be progress monitored and evaluated.
The intervention is being delivered in a manner which is consistent with the intervention details as described above.
The intervention seems appropriate for the needs of this student.
The individual(s) responsible for delivering intervention has the materials and support he/she needs.
The student’s attendance has not been a significant factor in hindering his/her progress.
The parent/guardian(s) of student received notification of the intervention plan. / The intervention is described in specific, measurable terms that can be progress monitored and evaluated.
The intervention is being delivered in a manner which is consistent with the intervention details as described above.
The intervention seems appropriate for the needs of this student.
The individual(s) responsible for delivering intervention has the materials and support he/she needs.
The student’s attendance has not been a significant factor in hindering his/her progress.
The parent/guardian(s) of student received notification of the intervention plan.
(Signature and Title of Person Completing Integrity Check) / (Signature and Title of Person Completing Integrity Check)
CURRENT LEVELS OF ACADEMIC AND BEHAVIORAL PERFORMANCE
Present Levels of Academic Performance Summary: Reading Math
Present Levels of Behavioral Performance Summary: Social Emotional Behavioral
Include results of the initial or most recent evaluation, including, if appropriate, the results of any universal screening, interventions, progress monitoring and gap analyses.
Results / Data Source / Date
Does this area impact the student’s academic achievement? Yes No
Does this area impact the student’s behavioral performance? Yes No
MEASURABLE LONG RANGE GOAL
Goal # / Measurable Long Range Goal / Measure
1
Obj. # / Short-Term Instructional Objectives/Benchmarks
1.1
1.2
1.3
1.4
1.5
Details of Intervention
Describe supplemental and/or small group strategies utilized – should be backed by scientifically-based research (SRB)
Provide specific evaluation criteria, in measurable terms, utilized to determine effectiveness and monitor progress. / Frequency and duration (time) of interventions
Name(s) and role(s) of individual(s) responsible for delivering intervention(s). / Name / Role/Responsibility
Parental Notification: / Student’s parent(s) notified of Tier III intervention (check one): Yes No
Date and method of notification: / Conference Phone Conference Mail
Report of Progress
Methods of Measurement / Progress on Long Range Goal
OBS = Observation
CRT = Criterion-Referenced Test
CBM = Curriculum-Based Measure
WS = Work Samples
D/P = Demonstration/Performance
Other: / A. The student is making sufficient progress to meet the long-range goal.
B. The student is making insufficient progress to meet the long-range goal. (A TST meeting must be held to discuss revisions.)
C. The long-range goal has been met or exceeded.
D. This long-range goal has not been introduced yet.
Date of Report / Current Level of Performance for Report of Progress
Describe the student’s current performance on the long-range goal based on progress on short-term objectives/benchmarks using the identified method of measurement (OBS, CRT, CBM, WS, D/P, etc.).
**Attach Data Source/Provide Parents with Data Summary / Progress Code
Notification of Progress Provided to Parents/Guardians
Type / Progress Notes / Report Cards / Goals Sheets / Other
Frequency / Every 4 ½ weeks / Every 6 weeks / Every 9 Weeks / Other
Integrity Checks for Tier III Intervention(s)
Instructions: School administrators, check the box next to each trait of quality implementation demonstrated during observation. Complete at least two (2) integrity checks at equal intervals during course of intervention.
Integrity Check #1 / Date: / Integrity Check #2 / Date:
The intervention is described in specific, measurable terms that can be progress monitored and evaluated.
The intervention is being delivered in a manner which is consistent with the intervention details as described above.
The intervention seems appropriate for the needs of this student.
The individual(s) responsible for delivering intervention has the materials and support he/she needs.
The student’s attendance has not been a significant factor in hindering his/her progress.
The parent/guardian(s) of student received notification of the intervention plan. / The intervention is described in specific, measurable terms that can be progress monitored and evaluated.
The intervention is being delivered in a manner which is consistent with the intervention details as described above.
The intervention seems appropriate for the needs of this student.
The individual(s) responsible for delivering intervention has the materials and support he/she needs.
The student’s attendance has not been a significant factor in hindering his/her progress.
The parent/guardian(s) of student received notification of the intervention plan.
(Signature and Title of Person Completing Integrity Check) / (Signature and Title of Person Completing Integrity Check)
CURRENT LEVELS OF ACADEMIC AND BEHAVIORAL PERFORMANCE
Present Levels of Academic Performance Summary: Reading Math
Present Levels of Behavioral Performance Summary: Social Emotional Behavioral
Include results of the initial or most recent evaluation, including, if appropriate, the results of any universal screening, interventions, progress monitoring and gap analyses.
Results / Data Source / Date
Does this area impact the student’s academic achievement? Yes No
Does this area impact the student’s behavioral performance? Yes No
MEASURABLE LONG RANGE GOAL
Goal # / Measurable Long Range Goal / Measure
1
Obj. # / Short-Term Instructional Objectives/Benchmarks
1.1
1.2
1.3
1.4
1.5
Details of Intervention
Describe supplemental and/or small group strategies utilized – should be backed by scientifically-based research (SRB)
Provide specific evaluation criteria, in measurable terms, utilized to determine effectiveness and monitor progress. / Frequency and duration (time) of interventions
Name(s) and role(s) of individual(s) responsible for delivering intervention(s). / Name / Role/Responsibility
Parental Notification: / Student’s parent(s) notified of Tier III intervention (check one): Yes No
Date and method of notification: / Conference Phone Conference Mail
Report of Progress
Methods of Measurement / Progress on Long Range Goal
OBS = Observation
CRT = Criterion-Referenced Test
CBM = Curriculum-Based Measure
WS = Work Samples
D/P = Demonstration/Performance
Other: / A. The student is making sufficient progress to meet the long-range goal.
B. The student is making insufficient progress to meet the long-range goal. (A TST meeting must be held to discuss revisions.)
C. The long-range goal has been met or exceeded.
D. This long-range goal has not been introduced yet.
Date of Report / Current Level of Performance for Report of Progress
Describe the student’s current performance on the long-range goal based on progress on short-term objectives/benchmarks using the identified method of measurement (OBS, CRT, CBM, WS, D/P, etc.).
**Attach Data Source/Provide Parents with Data Summary / Progress Code
Notification of Progress Provided to Parents/Guardians
Type / Progress Notes / Report Cards / Goals Sheets / Other
Frequency / Every 4 ½ weeks / Every 6 weeks / Every 9 Weeks / Other
Integrity Checks for Tier III Intervention(s)
Instructions: School administrators, check the box next to each trait of quality implementation demonstrated during observation. Complete at least two (2) integrity checks at equal intervals during course of intervention.
Integrity Check #1 / Date: / Integrity Check #2 / Date:
The intervention is described in specific, measurable terms that can be progress monitored and evaluated.
The intervention is being delivered in a manner which is consistent with the intervention details as described above.
The intervention seems appropriate for the needs of this student.
The individual(s) responsible for delivering intervention has the materials and support he/she needs.
The student’s attendance has not been a significant factor in hindering his/her progress.
The parent/guardian(s) of student received notification of the intervention plan. / The intervention is described in specific, measurable terms that can be progress monitored and evaluated.
The intervention is being delivered in a manner which is consistent with the intervention details as described above.
The intervention seems appropriate for the needs of this student.
The individual(s) responsible for delivering intervention has the materials and support he/she needs.
The student’s attendance has not been a significant factor in hindering his/her progress.
The parent/guardian(s) of student received notification of the intervention plan.
(Signature and Title of Person Completing Integrity Check) / (Signature and Title of Person Completing Integrity Check)
SPECIAL CONSIDERATIONS*
Behavior Intervention / N/A
In the case of a student whose behavior impedes the student’s learning or the learning of other student, consideration is given to the use of positive behavior interventions, supports, and other strategies to address that behavior.
Does the student have/need a functional behavioral assessment (FBA)? Yes No / Assessment Date:
Does the student have/need a behavior intervention plan (BIP)?**
Yes No / Implementation Date:
Has the behavior intervention plan (BIP) been reviewed / revised?
Yes No / Review Date:
Revision Date
Document the basis for the decision:
**If a student has a BIP, s/he must have a corresponding long range goal(s) to address behavioral concerns.
Services for Student with Limited English Proficiency / N/A
In the case of a student with limited English Proficiency, consideration is given to the language needs of the student as such needs relate to the student’s Intervention.
Describe the specific needs and document the basis for the decision:

* Indicate Special Considerations in the Summary of Performance.

Tier III Support
Standard Protocol Intervention (Academy of Reading, Academy of Math, Other ______)
Must provide minimum of two (2) integrity checks at equal intervals each term during intervention implementation. Attach to plan when Standard Protocol Intervention integrity checks are completed
Standard Protocol intervention / Area / Location / Start Date / Duration/Frequency / End Date
Document basis for the decision:
Instructional/Functional Accommodations/Modifications
Service / Area / Location / Start Date / Duration/Frequency / End Date
Document basis for the decision:
Support Services (Additional Counseling, etc.)
Service / Area / Location / Start Date / Duration/Frequency / End Date
Document basis for the decision:
Area
a.  Reading
b.  Spelling
c.  English
d.  Math
e.  Social Studies / f.  Science
g.  Health
h.  Lunch
i.  PE
j.  Guidance/Counseling / k.  Music
l.  Art
m.  Computer Science
n.  Clubs
o.  Recreation Activities / p.  Title I
q.  Tech Prep
r.  Vocational
s.  Library
t.  All Subjects / u.  Other:
v.  Other:
w.  Other:
x.  Other:
y.  Other:


Transition Plan