POTTERVILLE PUBLIC SCHOOLS

Pyramid of Intervention

Tier 1: General Education

All Students, Preventative and Proactive,
Flexible Grouping, Differentiated Instruction

Tier 2: Targeted/Supplemental Support

10-15% of Student Population, Small
□ 1. Meet with Principal to Schedule Groups, Rapid Response, Help Sessions
CST and Identify Members
Tier 3: Strategic or Intensive Support
□ 2. Review Student Data/Current
Classroom Intervention Plan with CST 5-10% of Student Population, Individualized
or Very Small Group Work, High Intensity
□ 3. Plan Additional Interventions,
Timeline, and Staff to Implement

□ 4. Weekly Communication to
Parents

*continue to monitor intervention

effectiveness

□ 1. Inform Principal of Concerns, Discuss further

Consultation

□ 2. Evaluate and Adjust General Education

Supports, Monitor and Document on Tier 2 Form

□ 3. Document Applied Interventions and Results

□ 4. Classroom Observation(s) by Principal

*if students is showing progress, continue interventions. If
not, initiate CST Appointment

□ 1. Collect District (NWEA) & State Data, SRI Data, SWIS Data, Review
CA60

□ 2. Discuss Student Traits with Previous Year Teacher, Parents, Social 3-6 Weeks
Worker (if applicable)

□ 3. Conference with Student to Set Goals and Document as appropriate

□ 4. Complete Tier 1 Form, Refer to Intervention Sources and Design

Differentiated Support to Address Concern
*if student is showing progress, continue with intervention
 TIER 1 INTERVENTION FORM
Potterville Public Schools

Student Name: Grade: Passed Vision Screening:

□ Yes □ No □ Unknown
Teacher Name: Previous CST Consultation: Passed Hearing Screening:

□ Yes □ No □ Yes □ No □ Unknown

Is Attendance a Concern? Was Student Retained? Medication? Special Ed:

□ Yes □ No □ Yes □ No □ Yes □ No

Concerns: List Specific Concerns:

□ Reading
□ Reading Comprehension
□ Math Calculation
□ Math Reasoning
□ Writing Expression
□ Behavioral/Emotional
□ Speech and Language
□ Fine and/or Gross Motor Skills
□ Organization

Factors to Consider:
Is there a language other than English spoken by this student or spoke in the student’s home? Yes No
Does this student exhibit emotional difficulties that interfere with learning? Yes No
Is there a relationship with poor academic achievement due to transiency, homelessness, or
Yes No
absenteeism?
Is the student motivated to perform or participate? Yes No
Has the student’s academic performance fallen dramatically within the last 6-12 months? Yes No
Is there knowledge of any situations within the student’s family that would contribute to drop in
academic performance?
Specify if known: Yes No

Please indicate progress of strategies and details on the reverse side. Use the following scale to rate student
performance on weekly basis:

4 Exceeds Expectations
3 Meets Expectations
2 Somewhat Meets Expectations
1 Does Not Meet Expectations
 Goal #1:

Data Statement (Baseline):

Strategy:

Progress?
Baseline Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Yes or No

Goal #2:

Data Statement (Baseline):

Strategy:

Progress?
Baseline Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Yes or No

Notes:

Resources with Brief Explanation to Intervene:

This site includes academic and behavioral interventions that can be used for K-12 students with some adapting to
make more age appropriate. It also provides templates to use for progress monitoring. Blogs are also available on
specific topics to gain a better understanding.
Intervention Central

This page is intended to give teachers a resource for obtaining class-wide or individual interventions that have been
found to meet the criteria for “evidence-based” as required in the determination of a student’s responsiveness to
intervention. Interventions are provided below in a variety of categories to meet your needs. For example, you might
search according to the level of intensiveness or appropriateness to grade level.
Intervention Web

The following site offers checklists and goals when establishing interventions. It also provides ideas on how to
incorporate opportunities for interventions.
RtI Toolkit: A Guide for Schools
 TIER 2 INTERVENTION FORM
Potterville Public Schools

Student Name: Teacher Name:

Start Date: End Date:

Intervention:

Person Responsible: Number of Sessions Length of Each Assessment to Growth:

per Week: Session: Monitor Progress:

Intervention:

Person Responsible: Number of Sessions Length of Each Assessment to Growth:

per Week: Session: Monitor Progress:

Progress Monitoring Scores: 4 Exceeds Expectations

3 Meets Expectations
Week #4 Week #5 Week #6
2 Somewhat Meets Expectations
1 Does Not Meet Expectations

Additional Comments:

***Please bring this form to the CST Meeting

 TIER 3 INTERVENTION FORM - CHILD STUDY TEAM REPORT
Potterville Public Schools

Student Name: Date:

School: Follow Up Meeting:

□ Yes □ No Date: ___________________

Grade:

Student Strengths Parent Input Classroom Observation Continued Specific

Areas of Concern

Previous Goal:

Intervention Results:

Previous Goal:

Intervention Results:
Baseline Data:

Current Level Data:

New Intervention Plan Person Responsible Start Date

Final Decisions and/or Other Recommendations

Parent Name: School Psychologist:

General Education Teacher: Social Worker:

Special Education Teacher: Occupational Therapist:

Speech/Language Pathologist: Special Education Director:

Other: Principal:
 STUDENT GOAL SETTING PLAN
Potterville Public Schools
Student Name: Teacher Name:

Date of Conference: Focus Area:

What am I having the Most Difficulty with in Class?

What is my Goal to Overcome this?

What do I Need to Reach my Goal: Who Can Help Me?

What is the First Step in Achieving my Goal?

Student Signature: Date:

Teacher Signature: Date:

Parent Signature: Date:

Other: Date:

Other: Date:

Other: Date: