RTI/AIS Student Intervention Plan

Elba Central School District

Student Interventionist

Date Intervention Total # of Weeks in

Plan was Written Intervention AND
the Tier
Date Intervention Date Intervention
Plan is to Start Plan is to End
Description of
Student Concern
(backed with data)

SMART Goal(s) for Intervention Plan (Specific, Measurable, Attainable, Relevant, Timely)
What to write: Write a SMART goal for this individual student. Remember to be very specific about what you want to
accomplish and why. Name the skills you’ll be working on with the child.

Individual Intervention Plan

What to write: Write a brief description of the intervention(s) to be used with the student. Name the specific strategies that will
be used and be sure they are research-based. (NOTE: If you have a script for this intervention, just write its name here and attach
the script.)
 Progress Monitoring
What to write: Write the method you will use to monitor student progress. For each method used, record the assessment to be
used, the data to be collected, the student’s baseline, the student’s individualized goal, and note how frequently you plan to monitor
the intervention. Keep in mind that Tier II interventions must be monitored a minimum of every two weeks, Tier III every week.
Assessment Measure/Data to be Collected: Progress Monitoring Ideas
for Interventions
• Student Data (grades,
Student’s Baseline Student’s Individualized Goal homework, attendance,
discipline, etc.)
• Rubric
Frequency Data will be Collected: (daily, every other day, weekly, etc.)
• Curriculum-based
Measurement
• Behavior Chart

Next Meeting Date to Review Data: __________________________________________

Effectiveness of Intervention (to be filled out after intervention is implemented)

What to write: Write about the effectiveness of the intervention. Was it successful? How do you know? Refer back to your
progress monitoring information. Also include what the next steps will be. Does the student need to continue the intervention?
Does he/she return to Tier I or Tier II? Does he/she need to move to Tier II or III? Remember to use data to support your decision.
Effectiveness of Intervention:

Next Steps: