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1st Six Weeks

Is the student in need of intervention? ____Yes ____ No


* Complete the form below only if the student received a grade below 70% on Report Card or Assessment Data.

Excellent Satisfactory Needs Improvement Referrals:


Conduct      

SUBJECT: ___________________________

Target Skill(s): __________________________________


__________________________________
__________________________________
__________________________________

Interventions COMMENTS:
SUBJECT:
After _________________________
School Tutoring Sheltered Instruction Observation Protocol (SIOP) CEI Lab
___________________________
Saturday Tutorials Reading Eggs Program Hands-On Activities
Target Group
Peer/Small Skill(s): __________________________________
Tutoring Dual Language Instruction Counseling ___________________________
Think Through Math __________________________________
Content Area Camps Immediate Feedback
I-Station Journal Writing
__________________________________ Morning Intervention ___________________________
Family Reading/Math Leveled Readers Planning/Intervention
__________________________________
Emergent Literacy Instruction Mentor RTI ___________________________
Literacy Teacher Intervention Reading Renaissance (A.R.) Individual Goals Other
Guided Reading Content Mastery
___________________________
Fluency Checks Pull Out ___________________________
___________________________
PARENT CONFERENCES:
Date Reason Plan of Action Parent Signature

2nd Six Weeks


Is the student in need of intervention? ____Yes ____ No
 Complete the form below only if the student received a grade below 70% on Report Card or Assessment Data.

Excellent Satisfactory Needs Improvement Referrals:


Conduct      

SUBJECT: ___________________________

Target Skill(s): __________________________________


__________________________________
__________________________________
__________________________________

Interventions COMMENTS:
AfterSUBJECT:
School Tutoring _________________________
Sheltered Instruction Observation Protocol (SIOP) CEI Lab
___________________________
Saturday Tutorials Reading Eggs Program Hands-On Activities
Target
Peer/Small Skill(s):
Group Tutoring __________________________________
Dual Language Instruction Counseling ___________________________
Think Through Math __________________________________
Content Area Camps Immediate Feedback
I-Station Journal Writing
__________________________________ Morning Intervention ___________________________
Family Reading/Math Leveled Readers Planning/Intervention
Emergent Literacy Instruction
__________________________________
Mentor RTI ___________________________
Literacy Teacher Intervention Reading Renaissance (A.R.) Individual Goals Other
Guided Reading Content Mastery
___________________________
Fluency Checks Pull Out ___________________________
___________________________
PARENT CONFERENCES:
Date Reason Plan of Action Parent Signature

3rd Six Weeks


Is the student in need of intervention? ____Yes ____ No
* Complete the form below only if the student received a grade below 70% on Report Card or Assessment Data.

Excellent Satisfactory Needs Improvement Referrals:


Conduct      

SUBJECT: ___________________________

Target Skill(s): __________________________________


__________________________________
__________________________________
__________________________________

Interventions COMMENTS:
SUBJECT:
After _________________________
School Tutoring Sheltered Instruction Observation Protocol (SIOP) CEI Lab
___________________________
Saturday Tutorials Reading Eggs Program Hands-On Activities
Target Group
Peer/Small Skill(s): __________________________________
Tutoring Dual Language Instruction Counseling ___________________________
Think Through Math __________________________________
Content Area Camps Immediate Feedback
I-Station Journal Writing
__________________________________ Morning Intervention ___________________________
Family Reading/Math Leveled Readers Planning/Intervention
__________________________________
Emergent Literacy Instruction Mentor RTI ___________________________
Literacy Teacher Intervention Reading Renaissance (A.R.) Individual Goals Other
Guided Reading Content Mastery
___________________________
Fluency Checks Pull Out ___________________________
___________________________
PARENT CONFERENCES:
Date Reason Plan of Action Parent Signature

4th Six Weeks

Is the student in need of intervention? ____Yes ____ No


* Complete the form below only if the student received a grade below 70% on Report Card or Assessment Data.

Excellent Satisfactory Needs Improvement Referrals:


Conduct      

SUBJECT: ___________________________

Target Skill(s): __________________________________


__________________________________
__________________________________
__________________________________

Interventions COMMENTS:
SUBJECT: _________________________
Sheltered Instruction Observation Protocol
After School Tutoring (SIOP) CEI Lab ___________________________
Saturday Tutorials Reading Eggs Program Hands-On Activities
Target Group
Peer/Small Skill(s): __________________________________
Tutoring Dual Language Instruction Counseling ___________________________
Think Through Math __________________________________
Content Area Camps Immediate Feedback
I-Station __________________________________
Journal Writing Morning Intervention ___________________________
Family Reading/Math Leveled Readers Planning/Intervention
__________________________________ ___________________________
Emergent Literacy Instruction Mentor RTI
Literacy Teacher Intervention Reading Renaissance (A.R.) Individual Goals Other ___________________________
Guided Reading Content Mastery
Fluency Checks Pull Out ___________________________
___________________________
PARENT CONFERENCES:
Date Reason Plan of Action Parent Signature

5th Six Weeks

Is the student in need of intervention? ____Yes ____ No


* Complete the form below only if the student received a grade below 70% on Report Card or Assessment Data.

Excellent Satisfactory Needs Improvement Referrals:


Conduct      

SUBJECT: ___________________________

Target Skill(s): __________________________________


__________________________________
__________________________________
__________________________________

Interventions COMMENTS:
SUBJECT: _________________________
After School Tutoring Sheltered Instruction Observation Protocol (SIOP) CEI Lab
___________________________
Saturday Tutorials Reading Eggs Program Hands-On Activities
Target
Peer/SmallSkill(s): __________________________________
Group Tutoring Dual Language Instruction Counseling ___________________________
Think Through Math __________________________________
Content Area Camps Immediate Feedback
I-Station Journal Writing
__________________________________ Morning Intervention ___________________________
Family Reading/Math Leveled Readers Planning/Intervention
__________________________________
Emergent Literacy Instruction Mentor RTI ___________________________
Literacy Teacher Intervention Reading Renaissance (A.R.) Individual Goals Other
Guided Reading Content Mastery
___________________________
Fluency Checks Pull Out ___________________________
___________________________
PARENT CONFERENCES:
Date Reason Plan of Action Parent Signature

6th Six Weeks

Is the student in need of intervention? ____Yes ____ No


* Complete the form below only if the student received a grade below 70% on Report Card or Assessment Data.
Excellent Satisfactory Needs Improvement Referrals:
Conduct      

SUBJECT: ___________________________

Target Skill(s): __________________________________


__________________________________
__________________________________
__________________________________

Interventions COMMENTS:
SUBJECT:
After _________________________
School Tutoring Sheltered Instruction Observation Protocol (SIOP) CEI Lab
___________________________
Saturday Tutorials Reading Eggs Program Hands-On Activities
Target Group
Peer/Small Skill(s): __________________________________
Tutoring Dual Language Instruction Counseling ___________________________
Think Through Math __________________________________
Content Area Camps Immediate Feedback
I-Station Journal Writing
__________________________________ Morning Intervention ___________________________
Family Reading/Math Leveled Readers Planning/Intervention
__________________________________
Emergent Literacy Instruction Mentor RTI ___________________________
Literacy Teacher Intervention Reading Renaissance (A.R.) Individual Goals Other
Guided Reading Content Mastery
___________________________
Fluency Checks Pull Out ___________________________
___________________________
PARENT CONFERENCES:
Date Reason Plan of Action Parent Signature

End of Year Recommendations for


20__ - 20__ School Year

READING MATHEMATICS
Performance: Performance:
 Masters Grade Level  Masters Grade Level
 Meets Grade Level  Meets Grade Level
 Approaches Grade Level  Approaches Grade Level
 Did Not Meet Grade Level  Did Not Meet Grade Level
Did student receive during school interventions? Did student receive during school interventions?
 Yes  Yes
 No  No

Did student receive tutoring services? Did student receive tutoring services?
 Yes  Yes
 No  No

What setting works for the student? What setting works for the student?

The student needs the following strategies to be The student needs the following strategies to be
successful: successful:

1. ________________________________ 1. ________________________________
2. ________________________________ 2. ________________________________
3. ________________________________ 3. ________________________________
4. ________________________________ 4. ________________________________
5. ________________________________ 5. ________________________________

RTI status (if student had a packet) RTI status (if student had a packet)

Teacher Signature: __________________________________________

Date: ______________________

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