Intervention Documentation Form Sevier County Schools; Sevierville, Tennessee Dear Parent: As we have discussed, I am attempting to improve your child’s skills in . This form describes what I have been doing and how well it is working. Please contact me if you have any questions. Student Name: Teacher: Description of the Intervention: Person responsible: Number of Sessions per week: Length of Each Session: Assessment used to monitor progress (DIBELS/Aimsweb (name which part), Number of known math facts, etc.): Target score: Baseline scores (at least 3 scores obtained before the intervention began): _______ _______ _______ Progress Monitoring scores (at least one per week of the intervention): Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Note number of session(s) student missed due to absence or other reason: Dates form sent to parents (must be at least every 4 ½ weeks): Comments: Validity Statement: I certify that the above noted intervention was implemented as described. _______________________________ Teacher Signature Date of signature Teachers must bring this form to second Problem-Solving Team Meeting. A student CANNOT meet standards for a Learning Disability if this form is not completed!