ACADEMIC INTERVENTION DEVELOPMENT TEMPLATE This template may be used to develop the academic intervention plan in the Schoolnet Interventions Module. Student Name Student ID

Grade

Teacher Name Course / Period The intervention plan will be in place for a minimum of 9 weeks beginning on

and ending on

.

Identify area(s) of concern according to data List the area of concern that requires immediate attention. Place an “X” in the appropriate box. Then list the data that was analyzed to determine the need for intervention. Include the student’s performance score on the data that was analyzed to prompt the intervention plan. Add notes if necessary.

Reading

Data

Score

Mathematics

Data

Score

Notes

Select the intervention and progress monitoring measurement to address the area of concern Use the Intervention Guide to identify an appropriate intervention and progress monitoring measurement that will be provided to the student to address the identified area of concern. Also, identify the expected student performance goal at the end of the intervention period.

Intervention Progress Monitoring Measurement

Goal

Progress Monitoring Frequency and Intervention Provider List the frequency that the intervention will be provided with the student and the frequency of when the progress monitoring score will be documented in the district’s database. Place an “X” in the appropriate box.

Frequency (Check one box) Daily

Weekly

Biweekly

Intervention Provider List the name of staff responsible for intervention delivery and progress monitoring.

Delivery of Intervention Progress Monitoring Documentation (entering the points in the district’s database) Parent/Guardian Contact Information Father’s Name

Phone Number

Mother’s Name

Phone Number

Approvals Teacher Counselor Campus Administrator

Signature

Date

Instructional Support Services Updated 10/9/2015