Instructional Intervention Documentation Sheet for Tier Three

Print all information (exceptions are signatures) TST-10 Submit with TST 1-9 and if applicable Intervention Documentation for Tier III TST-B1, TST-B2, TST-B3, and TST-B4

Student: Tier Three Data: ______Intervention Start Date: ______First MI Last Intervention End Date: ______

School: ECL ECU ECM ECH First Review Date: (No longer than 6 weeks after start date) ______

SME SMN SMU SMM SMH Sufficient Progress? : □ Yes □ No Final Review Date: (No longer than 18 weeks after start date) ______VLE VUE VMS VH Sufficient Progress? : □ Yes □ No If no, packet should be finalized and sent to District TST Office Grade: Intervention Conducted By: ______K 1 2 3 4 5 6 7 8 9 10 11 12 First MI Last Position: Teacher TST Interventionist Support Personnel: ______Teacher: (Position) ______Complete only if there more than one interventionist is being used: First MI Last Intervention Conducted By: ______First MI Last Position: Teacher TST Interventionist Support Personnel: ______Subject Area: (Position) An instructional intervention is a series of planned activities that are different from those activities normally occurring in the child’s regular education program. Place documentation (clearly labeled charts, graphs, etc.) behind form TST-10. What is the referring problem? (State in specific and measurable terms)

What data supports the existence of the problem? (Baseline data)

Describe the objective of the List the intervention source What was the outcome of the intervention? State in intervention in measurable terms. for each objective. measurable terms.

Comparison of Baseline data to goal data □ Planned intervention was successful in □ Planned intervention was not successful □ Planned intervention was not successful meeting the child’s needs. The in meeting the child’s needs. Another in meeting the child’s needs. Packet will be intervention will be continued in the instructional intervention will be conducted prepared and referred to District TST. current setting. to meet the child’s needs.

Signatures (First and Last Names) Position ______