Academic Intervention Plan (MTSS Tier 2/3)

Student Name: [Student name]

Student ID: [Student ID]

Grade: [Grade]

School/Site: [School or site]

Plan Type: [Tier 2 / Tier 3]

Plan Status: [Draft / Active / Revised / Closed] (Keep as Draft until baseline, dosage, progress monitoring measure, fidelity method, and next review date are all specified.)

Case Manager: [Name and role]

Plan Created: [Date]

Intervention Start Date: [Date] (Enter TBD if plan is Draft.)

Next Review Date: [Date]

Group Roster: [List student names and IDs; note whether goals are shared or individualized] (Include only for group intervention plans; omit entirely for individual plans.)

Presenting Concern

[Operational description of the specific academic skill deficit, instructional context where it occurs, and impact on access to grade-level content.] (Write 2–4 sentences using observable, measurable indicators. Avoid vague labels like "struggles with reading." If a working hypothesis about underlying subskills exists, add a sentence beginning with "Hypothesis:" Do not speculate about disability or diagnosis. If the concern cannot be operationally defined, write "Concern not yet operationalized—diagnostic assessment needed" and keep Plan Status as Draft.)

Baseline Data

Measure	Date(s)	Score(s)	Benchmark/Norm	Notes
[Measure name and type]	[Date(s)]	[Score(s)]	[Expected benchmark or norm]	[Administration conditions or relevant notes]
[Additional measure]	[Date(s)]	[Score(s)]	[Benchmark/Norm]	[Notes]

[Interpretation of what the data collectively indicate about current performance relative to grade-level expectations.] (Write 2–3 sentences. State instructional level versus grade-level performance.)

Baseline Calculation Rule: [Rule used, e.g., mean of 3 probes collected on specified dates]

Attendance During Baseline Window: [Attendance rate and relevant context] (Include only if relevant to interpretation; otherwise omit.)

Language of Assessment: [Language] (Include only if non-English or interpreter used; otherwise omit.)

Accommodations Used: [List accommodations, or omit if none]

Baseline Collection Plan: [Measure, schedule, and responsible person] (Include only if baseline data are pending; keep Plan Status as Draft until complete.)

Measurable Goal

By [target date or number of instructional weeks], given [materials and conditions], [student first name] will [observable academic behavior] at [criterion level with accuracy, fluency, or quality metric], as measured by [tool or probe], improving from baseline of [value and metric].

Goal-Setting Method: [benchmark-based / ROI-norms-based / intra-individual] — [Brief note on reference source or calculation used]

Supporting Instructional Focus Skills: [List specific subskills that support the primary outcome] (Include only if multiple skill strands are targeted; otherwise omit. Create separate measurable goals if more than one outcome will be monitored.)

Intervention Plan

Program and Rationale

Intervention Program: [Program, platform, or evidence-based routine name] — [Version or level]

Required Materials: [Materials, levels, and consumables]

[Rationale explaining why this intervention matches the identified need and skill profile.] (Write 2–3 sentences linking baseline data to program focus and evidence base.)

Instructional Approach

• Explicit Instruction Sequence: [Model → Guided Practice → Independent Practice structure with opportunities to respond and feedback]
• Error Correction Routine: [Corrective feedback sequence and rehearsal procedure]
• Transfer/Generalization Plan: [How skills will be applied to classroom tasks and core instruction]
• Scaffolds to Fade: [Supports provided and planned fading schedule]

Schedule and Dosage

Session Length: [Number] minutes

Sessions per Week: [Number]

Total Duration: [Number] weeks

Start Date: [Date]

End Date: [Date or "Through review date"]

Delivered by: [Role and title]

Setting: [push-in / pull-out / other]

Group Size: [Number of students]

Missed Session Procedure: [Make-up plan or rescheduling protocol]

(Dosage must be fully documented for the plan to be marked Active.)

Access Supports

[Language supports, assistive technology, engagement strategies, environmental modifications, and reference to any related behavior plan.] (Include only supports that apply to this student; omit section entirely if no additional supports are needed beyond standard intervention delivery.)

Fidelity Monitoring

Fidelity Tracking Method(s): [session log / direct observation / permanent products] (Select all that apply.)

Critical Components:

• [Component 1, e.g., scripted sequence followed]
• [Component 2, e.g., corrective feedback provided]
• [Component 3, e.g., planned duration completed]
• [Component 4, e.g., student engaged for target percentage of opportunities]
• [Component 5]

(List 3–5 critical components that define the intervention delivered as intended.)

Observation/Review Frequency: [Frequency, e.g., biweekly observation, weekly log review]

Recorded by: [Name and role] Reviewed by: [Name and role]

Fidelity Threshold: [Threshold, e.g., ≥80% of components implemented across two consecutive observations]

Action if Below Threshold: [Response plan, e.g., coaching, booster training, repeat check within specified days]

(At least one fidelity method and threshold must be specified before the plan is marked Active.)

Progress Monitoring

Measure: [Tool name and type—general outcome measure or curriculum-embedded]

Frequency: [weekly / biweekly / monthly] — [Rationale for frequency aligned to intervention intensity]

Administered by: [Name and role]

Baseline Rule: [Rule, e.g., mean of first 3 probes] (Must match rule used in Baseline Data section.)

Data Storage: [Platform or system for storing and graphing data]

Decision Rule Set: [four-point rule / trend-line analysis / median-based]

Decision Triggers: [Define data patterns that trigger: continue current plan, intensify, change approach, fade, or exit]

Data Review Schedule: [Meeting cadence, e.g., every 4–6 instructional weeks] with [participants: case manager, interventionist, classroom teacher, others as needed]

Review and Decision Criteria

Next Formal Review Date: [Date]

Response Level	Criteria	Action
Adequate	[Meets goal or on-track per decision rule]	[Maintain; consider fading; or raise goal]
Questionable	[Mixed data or insufficient improvement rate]	[Check fidelity; diagnostic reassessment; adjust dose or approach]
Inadequate	[Below goal line per decision rule]	[Intensify; change intervention; initiate Tier 3 if currently Tier 2]

Tier Movement Criteria: [Criteria to move Tier 2 → Tier 3 and criteria to exit intervention]

Special Education Evaluation Documentation: [Artifacts to compile: progress graphs, fidelity records, baseline data, intervention logs, parent communication log] (Include only if MTSS data may inform special education evaluation; otherwise omit.)

Communication

Parent/Guardian Notification: [Method and frequency]

Interventionist–Teacher Coordination: [Touchpoints and information exchange plan]

Student-Friendly Goal Statement: [Plain-language goal the student can track] (Include only if age-appropriate and used with student; otherwise omit.)