1. Granville County Public Schools
Student Intervention Action Plan
________________________________ School
Student: _____________________________________________Teacher/Grade _____________ Tier Level: _____Initial Date of Plan: ________________
Targeted Area of
Concern
Baseline Data:
Action Plan (for next 4 – 8 weeks)
Measurable Outcome Goal including method of measuring progress:
Interventions (Scientific/Research-based Strategy):
1.
2.
Frequency/Intensity (i.e. 30 min. a day, 3x a wk. in a small group of 3 assessed at least weekly):
1. 2.
Additional Instructional Strategies or Supports (Accommodations) Needed:
Significant Historical Information (ex. problems with attendance, previous retention)
Person(s) Responsible:
Monitoring of Plan
Monitoring of Plan: Date:
Acceptable Progress: _____ Monitor _____ Exit
Slow Progress: ______ Modify Plan _____ Move to Tier __________
No Progress: ______ Modify Plan _____ Move to Tier __________
Comments (include progress monitoring results and any modifications made to plan):

2. Monitoring of Plan: Date:
Acceptable Progress: _____ Monitor _____ Exit
Slow Progress: ______ Modify Plan _____ Move to Tier __________
No Progress: ______ Modify Plan _____ Move to Tier __________
Comments (include progress monitoring results and any modifications made to plan):
Monitoring of Plan: Date:
Acceptable Progress: _____ Monitor _____ Exit
Slow Progress: ______ Modify Plan _____ Move to Tier __________
No Progress: ______ Modify Plan _____ Move to Tier __ ________
Comments (include progress monitoring results and any modifications made to plan):
Monitoring of Plan: Date:
Acceptable Progress: _____ Monitor _____ Exit
Slow Progress: ______ Modify Plan _____ Move to Tier __________
No Progress: ______ Modify Plan _____ Move to Tier __________
Comments (include progress monitoring results and any modifications made to plan):
Monitoring of Plan: Date:
Acceptable Progress: _____ Monitor _____ Exit
Slow Progress: ______ Modify Plan _____ Move to Tier __________
No Progress: ______ Modify Plan _____ Move to Tier __________
Comments (include progress monitoring results and any modifications made to plan):

3. Monitoring of Plan: Date:
Acceptable Progress: _____ Monitor _____ Exit
Slow Progress: ______ Modify Plan _____ Move to Tier __________
No Progress: ______ Modify Plan _____ Move to Tier __________
Comments (include progress monitoring results and any modifications made to plan):
Monitoring of Plan: Date:
Acceptable Progress: _____ Monitor _____ Exit
Slow Progress: ______ Modify Plan _____ Move to Tier __________
No Progress: ______ Modify Plan _____ Move to Tier __________
Comments (include progress monitoring results and any modifications made to plan):
Monitoring of Plan: Date:
Acceptable Progress: _____ Monitor _____ Exit
Slow Progress: ______ Modify Plan _____ Move to Tier __________
No Progress: ______ Modify Plan _____ Move to Tier __________
Comments (include progress monitoring results and any modifications made to plan):
Monitoring of Plan: Date:
Acceptable Progress: _____ Monitor _____ Exit
Slow Progress: ______ Modify Plan _____ Move to Tier __________
No Progress: ______ Modify Plan _____ Move to Tier __________
Comments (include progress monitoring results and any modifications made to plan):