Action Plan Chart

Date:

Action Plan
Student Name:
Action to be Taken:

Justification
What will you learn from this action? (think about T-Skills and how your action will deepen your
understanding of the issue)

How is your action connected to your issue?

How will your action be sustained? How will you know that you have made an impact?

Organization
Date(s) of Action
Time(s)
Action Location

Equipment Needed (if any)

Contact Person (if any)

Other
Date(s) of Action
Additional Information (ie.
transporation etc.)

Evidence

How will you visually

record your evidence?
Who will assist you?
How will you gather written
evidence?
How will you document
feedback? Written?
Electronic?

Concerns
What concerns do you have
at this time?

What or who do you need to

help?

Approval
Signature
Student
Parent
Mentor
Teacher

Date