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Intervention Documentation Form

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Intervention Documentation Form Powered By Docstoc
					                             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!

				
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