(School or District Name Here)
Student Intervention Plan
Student Name:_______________________
Student Grade:_______________________
Start Date: __________________________
End Date: __________________________
Student Service Results (Indicate One
Total Hours Served: ________________
Successfully exited intervention
Exited to another intervention
Continue in Intervention
Moved from school
Graduated-Did not meet goals
Tier Status (Indicate One)
Tier 1
Tier 2
Tier 3
Intervention Type (Indicate One
Intervention Content Areas (Circle)
Reading/Writing (combined)
Science (Optional)
Social Studies (Optional)
Other (Explain below)
Intervention Materials 1
Teacher Developed Intervention Lesson
KDE Transitional
Post-Secondary Transitional
Vendor Program
Vendor Provided Service
 Other_______________________
Intervention Staff
Certified Peer Tutor
Classified Computer Based
 Other Staffing: (Explain below)
Delivery Method (Indicate One
In Person Blended
Other Delivery Method (Explain below):
Frequency (Indicate One)
2 days/week
Twice Monthly
3-4 days/week 
Other Frequency:
Duration (Indicate One)
< 30 minutes
60 minutes
30 minutes
> 60 minutes
45 minutes
Select all skill areas that apply
 Literacy Readiness Reading Fluency
 Reading Vocabulary Reading Phonics
 Reading Comprehension
 Writing Mechanics Hand Writing
 Writing Content
 Math Computation Math Reasoning
 Math Number Sense
 Math Numeracy Readiness
 Geometry
 Probability/Statistics Algebraic Thinking
 Social/Emotional
 Language
 Content Other
(School or District Name Here)
Student Intervention Plan
Parental Involvement
Parent Notified of Intervention Plan
Included in Planning
Provided Parent with Resources
 Parent Attended Intervention Meeting
Eye Exam
Medical Exam
Dental Exam
Other (Explain below):