Teacher Intervention Steps for Struggling Students
Student Name:
Step 1 – Student
□ Hold individual conference(s) with student
Date:
□
Fill out Student Responsibility Checklist
Date:
□
Provide suggestions for improvement. What suggestions were made?
□
Provide information on after-school tutoring
Date:
Step 2 – Parent
□
Notify parent/guardian of student’s problem.
□
Explain performance and suggest “helpful tips” (Briefly summarize parent contact)
Date:
Step 3 – Teacher
□
Review Pearson information/records
(Summarize any pertinent information provided)
□
Fill out General Education Teacher Intervention Checklist
Revised 10/6/10
Date:
FARMINGTON High School
General Education Teacher Intervention Checklist
Student ____________________________
Teacher _____________________________
Class______________Current Grade in Class:________ Date_________________________
Please mark the areas of concern that pertain to this student (check all that apply):
Factors that impact ACADEMIC PERFORMANCE
 Incomplete or late work, drop in performance
 Grades slipping-Failing
 Fails quizzes/tests
 Low motivation, not working up to potential
 Does little to no make up work
 Lack of participation
 Following directions
 Organizational skills difficulties
 Fine Motor skills difficulties
 Tardiness-# of days _____
 Inconsistent attendance-# of days______
 Sleeping in class or often drowsy
 Cheating
 Problem solving difficulties
 Reading/comprehension difficulties
 Problem with written expression
 Problem with verbal expression
 Other:
BEHAVIORAL CHARACTERISTICS
 Defiance
 Bullying or intimidating others
 Obscene language/gestures
 Fighting
 Outbursts of temper
 Withdrawing from others
 Disruptive in class
 Lying or stealing
 Promise to improve, but behavior doesn’t change Denies any problems
 Student reports family problems
 Withdrawn/loner
 Avoids people who have expressed concern
 Poor interpersonal relationship/social skills
 Inappropriate sexual references/language/actions  Verbal/written reference to suicide
 Drawing symbols (gang/cult-please note what  Mood changes from day to day
 Defensive, argumentative, hostile or
 Perfectionist
disrespectful
 Other:
FAMILY
 Parent (s) aware of your concern
 Parent (s) has similar concerns
 Parent (s) are supportive
 Parent (s) does not provide consistent
parenting method
 Parent (s) has other concerns-please list
 Parent (s) disciplines student when rules
are broken
 Other:
After identifying areas of concern, select and implement interventions and record on back.
Revised 10/6/10
Intervention Log Sheet
These are only suggested ideas for interventions; you should choose no more than 1 or 2 interventions to
implement at one time. You do NOT need to try all of them!
Explanation
No. of weeks
implemented:
Student centered:
1 2 3
Student Conference
Seating Change
__________________  
Student checklist given/discussed
Increase positive comments
__________________  
Reinforcement of correct responses
Extra teacher attention
__________________  
Individual instruction
Peer Centered:
Peer tutoring in class
Study partner in/out of class
__________________  
Which week(s)
in term: (1-12)
Comments:
_____
_____
_____
_____
Accommodations/Modifications:
Modification of assignment
Changing lesson plan to meet learning style
Use different learning approaches
__________________  
Note taking assistance (copy of notes)
Breaking task into small steps
__________________  
Extended time testing adaptation
Quiet setting testing adaptation
__________________  
Behavior/Academic Focus
Clarification of behavior rules
Clarification of academic rules
Classroom contract
Weekly effort report
Outside Assistance
Sent email progress report
Parent intervention (phone call)
Parent conference
Contact attendance office
Contact with counselor
Other Intervention:
_____
_____
_____
__________________  
_____
__________________  
_____
__________________  
_____
__________________  
_____
__________________  
_____
Teachers: Please keep accurate records of all interventions provided for this student.
You may contact Teacher Consultant, School Psychologist, or Social Workers to assist you in this data
collection.
If after implementation of chosen interventions, student is still failing or behavior has not changed,
please provide a copy of this form to the student’s school counselor.
Revised 10/6/10