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 How To Use
Start with the student profile page. This is helpful
information for the RtI or student study team who
may not be familiar with the student of concern.

It’s helpful to know if a student is younger, older,

or the same age as their classmates.

A variety of data measures show if the student

struggles in many areas (possible developmental
delay), or if they only struggle in one area (possible
learning disability or instructional gap).

You may have concerns about a student in more

than one area, but interventions need to be
focused. It’s like a science experiment where you
change only one variable and monitor for change.

Choose just ONE of the intervention pages. If you

move on to other interventions you can add on
additional pages.

This is where you define your targeted

intervention.

Choose an assessment that measures the

effectiveness of the intervention.

Take data at regular intervals to see how well the

80
intervention is working. You can add points in
60
between the vertical lines if you want to take data
40
over a longer period of time. The student’s score
20
before the intervention goes on the line labeled
“baseline.”

If the student is showing a reasonable amount of

progress then the intervention is working and
should be continued. If the child is showing little
or no growth then move on to another
intervention, a higher tier of the RtI model or
testing for special education.

As you carry out the intervention, record sessions on the included Intervention Implementation Notes form.
 Student Profile
Student Name: _______________________ Grade: _______ Birthdate: _________
Teacher: ______________________
English Language Learner Attendance Issues Has been retained

Baseline Data Include a variety of data, both in the area of concern and other areas.
Assessment Student’s Score Benchmark

Concerns
Parent contacted about concern on _________

Area of concern (circle): Reading Writing Math Behavior

Observations:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

©2015 Hannah Braun, The Classroom Key

Reading Intervention Documentation
Intervention Description Date:

__________________________________________ will participate in

student name

___________________________________ in a group with _____ other students.

intervention

The intervention will take place for _______ minutes, _______ times per week.

This intervention will target the area of _________________________________.

phonics fluency comprehension other

Data Collection
Assessment Used: ________________________________
Scores

Dates
©2015 Hannah Braun, The Classroom Key

Conclusion
Considering the data collected, does this intervention provide adequate support for
the student to move toward benchmark at a reasonable rate of speed?

yes, the intervention will be continued

no, another intervention will be tried or level of support will be increased

Writing Intervention Documentation
Intervention Description Date:

__________________________________________ will participate in

student name

___________________________________ in a group with _____ other students.

intervention

The intervention will take place for _______ minutes, _______ times per week.

This intervention will target the area of _________________________________.

spelling fluency grammar other

Data Collection
Assessment Used: ________________________________
Scores

Dates

Conclusion
Considering the data collected, does this intervention provide adequate support for
the student to move toward benchmark at a reasonable rate of speed?

yes, the intervention will be continued

no, another intervention will be tried or level of support will be increased

 Math Intervention Documentation
Intervention Description Date:

__________________________________________ will participate in

student name

___________________________________ in a group with _____ other students.

intervention

The intervention will take place for _______ minutes, _______ times per week.

This intervention will target the area of _________________________________.

counting computation problem solving other

Data Collection
Assessment Used: ________________________________
Scores

Dates
©2015 Hannah Braun, The Classroom Key

Conclusion
Considering the data collected, does this intervention provide adequate support for
the student to move toward benchmark at a reasonable rate of speed?

yes, the intervention will be continued

no, another intervention will be tried or level of support will be increased

Behavior Intervention Documentation
Intervention Description Date:

__________________________________________ will participate in

student name

___________________________________ in a group with _____ other students.

intervention

The intervention will take place for _______ minutes, _______ times per week.

This intervention will target the area of _________________________________.

social skills, task completion , following directions/rules, other

Data Collection
Assessment Used: ________________________________
Scores

Dates
©2015 Hannah Braun, The Classroom Key

Conclusion
Considering the data collected, does this intervention provide adequate support for
the student to move toward benchmark at a reasonable rate of speed?

yes, the intervention will be continued

no, another intervention will be tried or level of support will be increased

Speech/Language Intervention Documentation
Intervention Description Date:

__________________________________________ will participate in

student name

___________________________________ in a group with _____ other students.

intervention

The intervention will take place for _______ minutes, _______ times per week.

This intervention will target the area of _________________________________.

articulation, syntax, vocabulary, other

Data Collection
Assessment Used: ________________________________
Scores

Dates
©2015 Hannah Braun, The Classroom Key

Conclusion
Considering the data collected, does this intervention provide adequate support for
the student to move toward benchmark at a reasonable rate of speed?

yes, the intervention will be continued

no, another intervention will be tried or level of support will be increased

Intervention Implementation Notes
Use this form to record intervention sessions. Notes can include skills work on, progress, etc.

Date Notes

©2015 Hannah Braun, The Classroom Key

 Terms of Use
Please note, this product is for personal use by a single teacher. If you
would like additional copies for other teachers, please download
additional licenses available at 50% off the original purchase price. You
can purchase additional licenses through your ‘My Purchases’ page.
Purchase orders are welcome.

You May You May Not

*Use this product for your own
classroom/students
*Copy for use in your classroom by your
students
*Purchase licenses for others to use this
product at 50% off
*Give this product to others
*Copy this product for use by others
*Post this product to a website
*Copy or modify any part of this product
to offer others for free or for sale

©Copyright 2015. Hannah Braun, The Classroom Key. All rights reserved.
Permission is granted to copy pages for student or teacher use by the
original purchaser or licensee. Copying any part of this product and
placing it on the Internet in any form is strictly forbidden. Doing so is in
violation of the Digital Millennium Copyright Act (DMCA).