Tar

River Elementary School Student Intervention Action Plan Student: ____________________________________ Teacher/Grade: _____________________ Tier Level: ________ Initial Date of Plan ___________________ Targeted Area of Concern Baseline Data:

Action Plan (for next 4 8 weeks)

Measurable Outcome Goal including method of measuring progress:

Interventions (Scientific/Research-based Strategy):

1. 1.
Person(s) Responsible:

2.

Frequency/Intensity (i.e. 30 min. a day, 3x a wk. in a small group of 3 assessed at least weekly):

2.

Intervention Team Signature (Include Name, Title and Date) Names will vary depending on Tier Level

Monitoring of Plan (first monitoring MUST occur 6 8 weeks after initial implementation of plan)
Date: _________________________

Acceptable Progress: _____ Monitor _____ Exit Slow Progress: ______ Modify Plan _____ Move to Tier __________ No Progress: _____ Modify Plan _____ Move to Tier __________

Comments (include progress monitoring results and any modifications made to plan): Signature(s):
Date: _________________________

Acceptable Progress: _____ Monitor _____ Exit Slow Progress: ______ Modify Plan _____ Move to Tier __________ No Progress: _____ Modify Plan _____ Move to Tier __________

Comments (include progress monitoring results and any modifications made to plan): Signatures(s)
Date: _________________________

Acceptable Progress: _____ Monitor _____ Exit Slow Progress: ______ Modify Plan _____ Move to Tier __________ No Progress: _____ Modify Plan _____ Move to Tier __________

Comments (include progress monitoring results and any modifications made to plan): Signatures(s)
Date: _________________________

Acceptable Progress: _____ Monitor _____ Exit Slow Progress: ______ Modify Plan _____ Move to Tier __________ No Progress: _____ Modify Plan _____ Move to Tier __________

Comments (include progress monitoring results and any modifications made to plan): Signatures(s)