Fillable Individual-reading-plan-template Lbpa-fillable - Individual Reading Plan Template_LBPA

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Individual-reading-plan-template Lbpa-fillable - Individual Reading Plan Template_LBPA

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!
Student!Name:!____________________________________!!!!!!!!!!!!!!!!!Individua l!Rea din g!Pla n!
2!
!
!
!!!Note:!The!Individual!Reading!Plan!correlates!with!the!Multi-Tiered!System!of!Supports!(MTSS)!student!!!!!!!
!!documentation!required!for!*Tier!III!(Intensive!Intervention).!These!pages!may!be!used!when!meeting!with!!
!!the!Teacher!Support!Team!for!each!student!that!did!not!respond!to!Tier!II!Interventions;!4
th
!
grade!students!!
!!requiring!Intensive!Intervention!after!Good!Cause!Exemption!promotion;!or,!for!intensive!reading!!
!!interventions!for!Special!Education!students!(K-4)!and!English!Language!Learners!(ELLs).! !
!"#$%&"'()*%'+'
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Following!the!identification!of!a!reading!deficiency,!intensive!reading!instruction!and!intervention!
must!be!documented!for!each!student!in!an!individual!reading!plan,!which!includes,!at!a!minimum,!the!
following:!!
!!
(a)!The!student's!specific,!diagnosed!reading!skill!deficiencies!as!determined!(or!
identified)!by!diagnostic!assessment!data;!
!!
(b)!The!goals!and!benchmarks!for!growth;!!
!!
(c)!How!progress!will!be!monitored!and!evaluated;!!
!!
(d)!The!type!of!additional!instructional!services!and!interventions!the!student!will!receive;!!
!!
(e)!The!research-based!reading!instructional!programming!the!teacher!will!use!to!provide!
reading!instruction,!addressing!the!areas!of!phonemic!awareness,!phonics,!fluency,!
vocabulary!and!comprehension;!!
!!
(f)!The!strategies!the!student's!parent!is!encouraged!to!use!in!assisting!the!student!to!
achieve!reading!competency;!and,!!
!!
(g)!Any!additional!services!the!teacher!deems!available!and!appropriate!to!accelerate!the!
student's!reading!skill!development!
Student!Name:!____________________________________!!!!!!!!!!!!!!!!!Individua l!Rea din g!Pla n!
3!
!
!
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MSIS!Number/ID:'
School/Site:'
District:'
Date!of!Birth:!
Teacher:!
Gender:!
Race:!
Parent/Guardian!Name:! ! !
Phone:!
Email:!
Street!Address:!
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!
Recommended!Scale!
Score!
Student!Scale!
Score!
Fall!/!530!!
!
Spring!/!681!
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Fall!!
Winter!
Spring!
Reading!!
!
*_________________!
!
!
!
Math!
*_________________!
!
!
!
Behavior!
*_________________!
!
!
!
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!!*List!screener!and!date!administered!
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School!Year!!!!!!!!!Days!Present!/!Absent!
!____________!!!!!!!!!!!________!/!________!
!_____________!!!!!!!!!________!/!________!
!_____________!!!!!!!!!________!/!________!
!
Note:!Attach!MSIS!suspension!data,!if!
applicable.!
!
List!last!2!schools!attended!and!dates.!
1.!!!!!_____ __ _ __ _ __ __ _ __ __ _ __ !!!_ __ __ _ __ _!
2.!!!!!_______________________!!!_________!
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Instructions:!If!app licab le,!
indicate!g ra d e( s) !an d !sc ho o l!
year(s)!below.!!
!!!!!!!!!!!
!!!!!Grade!!!!!!!!!!!!!!!!School!Year!
!!!!___________!!!!!!!__________________!
!!!!___________!!!!!!!__________________!
!___________!!!!!!!__________________!
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Instructions:!Check!if!applicable!to!
student.!!
Special!Education!/!IEP!
!Initial!Eligibility!Date:!________!
!Eligibility!Category:!________!
504!
ELL!(Appendix!B)!
Dyslexia!
Other!_____________________!
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Initial!Test!
!!
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1st!Retest!
!!
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2nd!Retest!
!!
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Reading!
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!!
!!
!!
!!
Mathematics!
!!
!!
!!
!!
!!
Science!
!!
!!
!!
!!
!!
Social!Studies!
!!
!!
!!
!!
!!
Language!Arts!
!!
!!
!!
!!
!!
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Student!Name:!____________________________________!!!!!!!!!!!!!!!!!Individua l!Rea din g!Pla n!
4!
Baseline: _______________________ Goal: ________________________
!
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Intervention!Start!Date:!________________________________!
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D<"'31-#*%&"%$'7%65%O!Date:!___________________!!!!!!!!!!!!!!!!!!!!!!!!!!Sufficient!Progress!Made?!(circle!one):!Q%<'0'(1'
(to!be!completed!no!later!than!8!weeks!after!starting!intervention)!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!(!if!no,!an!additional!intervention!form!should!be!completed)!
:#*#2)"56%'31-#*%&"%$'7%65%O!Date:!___________________!!!!!!!!!!!Sufficient!Progress!Made?!(circle!one):!Q%<'0'(1'
(to!be!completed!no!later!than!16!weeks!after!starting!intervention)!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!(!if!no,!an!additional!intervention!form!sho uld!be !com plete d)'
Adequate!progress!was!made;!
intervent ion !was!
successful!in!meeting!
student’s!needs.!This!
student!will!be!returned!
to!the!following!tier:!
!Tier!I!
!Tier!II!
Re-evaluation!date:!___________!
!Adequate!progress!was!not!
made;!intervention!was!
somewhat!successful!in!
meeting!student’s!needs.!
Student!will!continue!at!
Tier!III!and!additional!
intervent ion !will!be!
attempted!(additional!
form—both!Section!3B!&!
3C!should!be!completed).!
Adequate!progress!was!not!
made;!intervention!was!
not!successful!in!meeting!
student’s!needs.!Referral!
to!child!study!on!(date):!!
!Student!currently!has!an!
IEP.!Complete!th e!
informat ion !in !th e !bo x !
below.!!
!!
Enter!Eligibility!Category!
!!!!!!!!!________________________!
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Instructions:!Teachers!should!complete!progress!monitoring!for!interventions.!It!is!recommended!that!the!teacher!
establish!a!baseline!by!administering!three!(3)!probes!or!trials,!selecting!the!median,!and!marking!the!baseline!by!
placing!a!dot!on!the!vertical!axis.!Teachers!should!determine!the!goal!by!determining!the!expected!rate!of!
progress!and!marking!the!target!by!placing!a!dot!at!the!intersections.!On!the!bolded!line!above!each!month,!
indicate!t he !firs t!re su l t!re co rd e d !th at !m o n th ;!o n !th e!lin e !to!the!right,!indicate!the!second!result!of!that!month.!!
Name!of!
Probe/Trial!
!
Refer to MTSS Documents
Student!Name:!____________________________________!!!!!!!!!!!!!!!!!Individua l!Rea din g!Pla n!
5!
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Instructions:!TST!members,!classroom!teachers,!and!interventionists!should!work!together!to!complete!
this!form!for!each!student!identified!as!needing!an!Individual!Reading!Plan!based!on!reading!
deficiencies.!!
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Phonemic!Awareness!
Phonics!
Fluency!
Vocabulary!
Comprehension!
!
Additional!supplemental!materials!(if!applicable):!
!
!
!
!
Student!Name:!____________________________________!!!!!!!!!!!!!!!!!Individua l!Rea din g!Pla n!
6!
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Parent!Read-at-Home!Plan!
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Parent!Initial:!______________________________!!!!!!!!!!!!!!!!!! !!!!!!!Date:!_________________________________!
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Parent!Initial:!______________________________!!!!!!!!!!!!!!!!!!!!!!!!!Date:!_________________________________!
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Individual-reading-plan-template Lbpa-fillable - Individual Reading Plan Template_LBPA

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Completed 20 November 2019

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