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Student Intervention Implementation Log

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National Center on Intensive Intervention Intervention Implementation Log—1
4651_12/15
Student Intervention Implementation Log
Purpose: This log can be used as a daily and weekly record of your implementation of an
individual student’s intervention plan. This information, along with progress monitoring
graphs, can inform team intervention and data review meetings.
Teacher: ________________________________________
Student: ________________________________________
Week of: ________________________________________
Intervention Implementation Log
Please fill out this log each day. If an intervention is not scheduled for a given day or could not
be offered (e.g., holiday, your absence), then please mark “N” under the column “Intervention
Offered?” and leave the rest of the row blank. On days when the student receives intervention
(Student Present? = Y), indicate the duration (minutes) or frequency (e.g., number of check-ins)
of the intervention, rate the extent of student engagement, and rate the plan implementation.
Day
Intervention
Offered?
Student
Present?
Intervention
Duration or
Frequency
Was the Student
Engaged?
No Partially Yes
Was the Intervention
Implemented as
Planned?
No Partially Yes
Monday
Tuesday
Wednesday
Thursday
Friday
☐Y ☐N ☐Y ☐N
☐Y ☐N ☐Y ☐N
☐Y ☐N ☐Y ☐N
☐Y ☐N ☐Y ☐N
☐ ☐ ☐ ☐
☐1 ☐2 ☐3
☐1 ☐2 ☐3
☐1 ☐2 ☐3
☐1 ☐2 ☐3
☐1 ☐2 ☐3
☐1 ☐2 ☐3
☐1 ☐2 ☐3
☐1 ☐2 ☐3
☐1 ☐2 ☐3
Y N
Y N ☐1 ☐2 ☐3
Please note any relevant information to explain the above ratings.
National Center on Intensive Intervention Intervention Implementation Log—2
End-of-Week Evaluation
Implementation
Reflecting on your daily ratings, please rate overall implementation this week.
No Partially Yes
Did you implement the intervention plan as intended this week?
☐1 ☐2 ☐3
☐1
☐2 ☐3
Did you implement the data collection plan as intended this week?
If you selected a 1 or 2 for either of the above items, then please note what occurred, including
any intervention adaptations that were not in the plan. Also, please note any additional relevant
information.
Nee
d for Further Adaptation
Do student data indicate the need for an adaptation to the intervention based on predetermined
decision rules?
☐ Yes
☐ No
Does the plan need to be changed due to barriers to implementation (e.g., the schedule does not
allow sufficient time, staff need more training)?
☐ Yes
☐ No
If an adaptation is needed (“Yes” to either question above), then consider the following:
What level of adaptation is needed to improve your plan for next week?
☐ Minor
☐ Major
Do you need to meet with the team before moving forward with the adaptation?
☐ Yes
☐ No
Next Week’s Action Plan
Please describe any planned modifications for next week.
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Completed 27 April 2021

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