University/On-site Mentor
Intervention Plan
NOTE: The University Supervisor is notified as early as possible concerning any prospective "D" or "F" intern. A
conference is scheduled with the intern, university supervisor, and on-site supervisor to develop a written intervention plan.
The intervention plan must include: a. requirements that must be met by the intern in order to improve the grade (or an
alternate plan for changing to a non-licensure track); b. date of re-evaluation and person responsible for follow up, and
c. signatures: intern candidate, on-site mentor, and university supervisor.
If the candidate is removed from the internship (by request of either LU or the K-12 school), a new field
placement to finish licensure requirements is NOT guaranteed; the candidate may need to change to a non-
licensure track.
University/On-site mentor:
Describe the nature of the concern:
Summarize the discussion:
State the requirements that must be met by the interns in order to complete the grade (or an alternative plan for
changing to a non-licensure track):
Person(s) responsible for follow-up with
Date for Re-Evaluation:
Consequences of Non-Compliance
Intern’s Signature:
University Supervisor’s Signature:
Onsite Mentor’s Signature
Program Director’s Signature:
Associate Dean’s Signature: