Problem Solving Team (Pst) Student Intervention Plan Form

DEKALB COUNTY SCHOOL SYSTEM

PROBLEM SOLVING TEAM (PST) STUDENT INTERVENTION PLAN FORM

SECTION I: FACTORS CONSIDERED IN DETERMINING NEED FOR INTERVENTION

Student’s Name: Sex: Race: Date: Click here to enter a date.

School: Click here to enter text. Grade: Age: Birth Date:

Specific Concern(s) to be addressed: (Choose one or more from the following):

Basic Reading / Reading Comprehension / Oral Expression
Math Calculation / Math Reasoning/Problem Solving / Listening Comprehension
Behavior / Reading Fluency / Written Expression
SECTION II: INTERVENTION PLAN/DOCUMENTATION OF APPROPRIATE INSTRUCTION
The student’s data has been reviewed and appropriate instructional strategies have been implemented with changes in the classroombased on the student’s needs.
The student has participated in small group instruction.
The student has participated in school-wide enrichment activities.
The student has participated in a tutorial program.
The student has participated in a private educational program.
The student has received the following standards-based instruction by highly qualified personnel in the general education setting.
TIER I & TIER II: (Within the general education program):
READING/ENGLISH LANGUAGE ARTS
Teacher(s) Responsible: Beginning Date:
Monitoring tool: Specific screening/benchmark data: Click here to enter text.
Instructional Program: Click here to enter text.
Number of Minutes Per Day: Click here to enter text.
Number of Days Per Week: Click here to enter text.
MATH
Teacher(s) Responsible: Beginning Date:
Monitoring tool: Specific screening/benchmark data: Click here to enter text.
Instructional Program: Click here to enter text.
Number of Minutes Per Day: Click here to enter text.
Number of Days Per Week: Click here to enter text.
TIER III:
NA
READING/ENGLISH LANGUAGE ARTS OR
Teacher(s) Responsible: Beginning Date:
Progress Monitoring Tool: Click here to enter text. INTERVENTION GOAL: In weeks, the student will:
Click here to enter text.
Instructional Program: Click here to enter text.
Number of Minutes Per Day: Click here to enter text.
Number of Days Per Week: Click here to enter text.
NA
MATH OR
Teacher(s) Responsible: Beginning Date:
Progress Monitoring Tool: Click here to enter text.INTERVENTION GOAL: In weeks, the student will:
Click here to enter text.
Instructional Program: Click here to enter text.
Number of Minutes Per Day: Click here to enter text.
Number of Days Per Week: Click here to enter text.
NA
BEHAVIOR (MUST have a behavior intervention plan & instruction to target the behavior.) OR
Teacher(s) Responsible: Beginning Date: Ending Date:
Progress Monitoring Tool: Click here to enter text.INTERVENTION GOAL: In weeks, the student will:
Click here to enter text.
Instructional Program: Click here to enter text.
Number of Minutes Per Day: Click here to enter text.
Number of Days Per Week: Click here to enter text.

SECTION III: Intervention Plan Review:

Date of Review #1: Click here to enter text.

Date of Review #2: Click here to enter text.

Date of Review #3: Click here to enter text.

SECTION IV: When Referring a Student for Special Education Evaluations:

Data-based documentation of repeated assessments of achievement at reasonable intervals reflecting formal assessment of student progress during instruction, which was provided to the child’s parents:

Prior to a referral for special education evaluation.
OR
As part of the referral process (Parent Referral) *AAC 2007-290-8-9.01(4)
AS PART OF THE DATABASED DOCUMENTATION, THE FOLLOWING MUST BE ATTACHED:
Attach Parent Letter Explaining Intervention Intiation (Appendix J-1). Notification of Parent’s Right to Request Evaluation
Attach Copies of All Intervention Progress Reports (Appendix J-2) sent home.

SIGNATURES:

PST MEMBER/Tier I & II Teacher: Click here to enter text.

PST MEMBER/Tier III Teacher: Click here to enter text.

PST MEMBER/Administrator: Click here to enter text.

FORM COMPLETED BY: Click here to enter text.

Revised 8/19/15

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