Intervention Summary & Documentation of Response to Intervention/Instruction
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S St. Lucie Public Schools Intervention Summary & Documentation of Response to Intervention/Instruction School Team Members Present: Grade Academic Behavior Tier 2 – Targeted Instruction/Intervention Tier 3 – Intensive Instruction/Intervention Date of Identification: Date of Response: (Recorded on Back) ______________________ _______________________ _______________________ ________________________ _________________________ ______________________ _______________________ _______________________ ________________________ _________________________ ______________________ _______________________ _______________________ ________________________ _________________________ ______________________ _______________________ _______________________ ________________________ _________________________ BRS /Phonemic Awareness BRS/Phonics Reading Fluency (Rate & Accuracy) Math Calculation Math App/PS Behavior Vocabulary Listening/Reading Comprehension Oral Expression Written Expression Intervention in addition to Core Curriculum Identified Intervention: _______________________________________________ Interventionist:________________________________________________ Implementation Schedule: Start Date: ______________ Duration(e.g. 30 min.) __________ Measurement Strategy: Progress Monitoring Tool:_______________________ Progress Monitoring Interval: 20 day intervals 15 day intervals Frequency(e.g. 5 days a week) _______________ Group Size: _________ 10 day intervals Weekly Daily Progress Monitoring Schedule: 1st _____________ 2nd _____________ 3rd _______________ 4th ______________ 5th ______________ 6th _____________ 7th ______________ 8th _______________ 9th ______________ 10th _____________ Fidelity monitor/support provided by: 1)____________________________________ Schedule of support: ____________________________________________ 2)______________________________________ Method of support: ___________________________________ Please list students receiving this intervention on Page 2. Revised 6-29-12 STS0137S p.1 S The School Board of St. Lucie County Intervention Summary & Documentation of Response to Intervention/Instruction Intervention Summary Expected Levels/Assessments Student Name 1)_____________ 2)_____________ ID # 3)______________ Level of Performance (Prior to Intervention) Documentation of Response to Instruction/Intervention 2) _______________ 3) ______________ Expected Levels/Assessments 1) _______________ Class Periods Consistent Level of Performance (After Intervention) Student Response Exit Continue Modify New Absent? Delivery? _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + _____________________________ __________________ 1)________ 2)________ 3)________ _________ Y/N 1)________ 2)________ 3) ________ - ? + The Group PST will meet the week prior to the Core PST meeting to review progress monitoring data. Support person may request a review earlier based on more frequent progress monitoring data. Revised 6-29-12 What percentage of the students in the targeted skill group showed positive response? ______ 70-80% = Option 1 = Change or modify intervention for unsuccessful students (MUST be 1st choice) Option 2 = Consider Tier 3 services for students with poor outcomes BUT positive fidelity. <70-80% = Go back to Problem Solving Worksheet to determine another Tier 2 group intervention. Dates of Fidelity Walk Through: 1st _________________ 2nd ________________ 3rd ________________ STS0137S p.2
