Inclusion & Intervention Plan: Essential Components

The Inclusion & Intervention Plan Review will be used for an intensive qualitative review of a small sampling of students who have been identified as requiring intensive supports. Please ensure that the following components have been addressed in the student’s Inclusion & Intervention Plan.

Student Name: Click here to enter text.

Ministry of Education ID Number: Click here to enter text.Grade:Click here to enter text.

Intensive Supports Level:☐Ior☐IIIntensive Supports Category: Click here to enter text.

Essential Component / Suggested Elements / Check
  1. Strengths and impact areas (needs) are recorded
General
1. Who is this student?
2. Learning Capacity
Medical/Diagnosis /
  • Based on formal and informal assessments including summative, formative and diagnostic
/ ☐Yes
☐No
Comments: Click here to enter text.
  1. Outcomes are consistent with impact areas
Targeted Areas
Planning for Student Overall
Overall Rubric Tab&
Tabs 1-10 /
  • Reflect impact areas from Impact Assessment Profile
  • Priority areas of need (typically 3-5)
  • Desired outcome
/ ☐Yes
☐No
Comments: Click here to enter text.
  1. Assessed level of performance is recorded
Targeted Areas Tabs 1-10 /
  • Current level of functioning for each outcome is clearly stated
  • Answers the question: “How well does the student do in the area now?”
/ ☐Yes
☐No
Comments: Click here to enter text.
  1. Sources of supports are recorded
Targeted Areas Tabs 1-10
Support, Frequency & Instructional Strategies /
  • Documented involvement of the school, school division, and other agency sources of support, including role and frequency
/ ☐Yes
☐No
Comments: Click here to enter text.
  1. Assessment procedures for monitoring and evaluating student progress are recorded.
Targeted Areas Tabs 1-10
Assessment – How will we measure this? /
  • May include: observations and work samples; diagnostic tests; developmental assessments; standardized tests; checklists; anecdotal records
/ ☐Yes
☐No
Comments: Click here to enter text.
  1. Efforts towards differentiated instructional strategies
Targeted Areas Tabs 1-10
Support, Frequency & Instructional Strategies /
  • May include: Co-Teaching; Tiered Assignments; Scaffolding; Content Enhancement; Individual, small group, and large group instruction.
/ ☐Yes
☐No
Comments: Click here to enter text.
  1. Transition are reflected
Transition Tab /
  • Prior and on-going planning towards independence and smooth transitions
/ ☐Yes
☐No
Comments: Click here to enter text.
8. Parental signature and documents uploaded
Files & Links Tab
File to Upload /
  • Parental engagement
/ ☐Yes
☐No
Comments: Click here to enter text.
9. Based on the provincial criteria, the documentation supports the identification of the student requiring intensive supports.
Division Approval Tab /
  • Completed by Central Office
/ ☐Yes
☐No
Comments: Click here to enter text.

SST’s Signature: ______Principal’s Signature: ______

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