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Tier 2 Form

           Jefferson Township Public Schools__________________


Tier 2 – Classroom Intervention










Level 2 Intervention Begin Date: _________________ 


1.       Identify student’s strengths.



2.       Identify student’s weakness.




3.       What motivates this student to try?





Identify the learning or behavior issue that needs to be addressed.  (Please be specific.)










5.      Choose a strategy or strategies that you will try with this student. (To view a list of possible interventions, click on the appropriate link below.) The BIM, PRIM, and LIM are also resources that can be found in the guidance office.

Attention         Behavior          Consequences             Cross-Curricular          Math   Handwriting Individualized Rules                        Quiet Alternatives       Organizational Interventions                 Parent Teacher Conference Planning                       Spelling               Transition Words Reading Interventions                    Positive Behavior Support

Identify the strategy or strategies you will implement in your classroom.



6.     What will the student do (observable and measurable behaviors) which will indicate that the intervention or interventions were successful?



7.        Parent notified of strategies/desired outcomes. Date  _________________ 
     (Briefly summarize parent contact.)


8.  Parent notified of progress?  Date
(Briefly summarize parent contact.)



9.  Results of intervention/interventions?


10.    Intervention successful/maintain strategies Date

11.    If intervention was unsuccessful, what will you try next?
     (Check all that apply) 
     Choose Alternate Strategy/Strategies
 _____   Parent/Teacher/Student Conference  ______

     Recommend Extra Intervention 
 ____            Vision/Hearing Screening    _____ 

Please describe how you will implement the intervention(s) checked.


12. Parent notified of new intervention plan/desired outcomes           Date
       (Briefly summarize parent contact.)



13.  Parent notified of progress? Date _________________ 
       (Briefly summarize parent contact.)



14.  Results of intervention /interventions?



15.  Intervention successful/maintain strategies Date _________________ 

16.   Intervention unsuccessful/  Move to  Tier 3-Referral Process   Date _________________ 

Subpages (1): Tier 2 Form with Blanks
Mar 11, 2013, 9:21 AM