Plymouth Joint School District Student Intervention Plan (SIT)

Student:	DOB:
Teacher:	Parent (s):
Building:	Parent (s):

Retained:	No Yes	If yes- what year/grade:
Attendance:	0-10 days 11 or more days
Health Concerns:	No Yes- Describe:
Current Services:	No Yes- Describe:

SIT Team Member & Role	Date:	Follow up *check if attended Date_____________	Follow up *check if attended Date______________

Purpose of meeting:	Date of Parent contact:
By:
Purpose of meeting:	Date of Parent contact:
By:
Purpose of meeting:	Date of Parent contact:
By:

Parent Input:
Strengths:

District & Formative Assessment Review:
Previous Accommodations:
Improvement:	Little Effect Moderate Effect Highly Effective
Previous Modifications:
Improvement:	Little Effect Moderate Effect Highly Effective
Previous Interventions:
Improvement:	Little Effect Moderate Effect Highly Effective

SIT Plan and goal focus:	Specify Focus skill:
Academic plan
Social-Emotional plan

Focus Area:	Describe struggling skills:
Oral Expression
Listening Comprehension
Math Calculation
Math Problem Solving
Basic Reading Skills
Reading Fluency
Reading Comprehension
Written Expression
Emotional Control
Sustained Attention
Impulse Regulation
Organization/ Study Skills
Classroom Expectations/ School wide Behaviors
Health/Physical

Targeted Intervention Plan #________	Date developed: _______________

SMART Goal (Specific, Measureable, Attainable, Relevant, Time Specific)
Intervention Strategy/ Program
Total number of instructional weeks
Start & End Date
Interventionist:
Academic/Behavioral Progress Monitoring Measure & frequency
Person Responsible

Reviewed Date: ________________________	Goal Met: Yes No

Intervention Data & Outcome:
Next Action:

Targeted Intervention Plan #________	Date developed: ____________________

SMART Goal (Specific, Measureable, Attainable, Relevant, Time Specific)
Intervention Strategy/ Program
Total number of instructional weeks
Start & End Date
Interventionist:
Academic/Behavioral Progress Monitoring Measure & frequency
Person Responsible

Reviewed Date: ________________________	Goal Met: Yes No

Intervention Data & Outcome:
Next Action: