Sample AIP - Reading

GPC Form A: SAISD Student Reading Data
Grade 5
ID Number: 00000001
Student: Jane Q. Student
Assessment Results / Summary Data
Complete the STAAR Information after each administration.
STAAR
1st Administration
Date 3/31/15
STAAR
RC 1
# Correct
RC 2
# Correct
RC 3
# Correct
18 of 46
_4_of 10
8_ of 19
_6_ of 17
____ of 46
2nd Administration
Date
3rd
Total #
Correct
STAAR
Administration
____of 46
Date __________
____of 10
____of 10
____ of 19
____of 19
____of 17
____ of 17
AREA FOR
ACCELERATION
Reporting Category
1 2 3
Reporting Category
1 2 3
Reporting Category
1 2 3
Other Reading Assessment Information
Fountas and Pinnell
Level
EOY Month _______
Istation
BOY
Month _______
MOY
Month _______
EOY
Month _______
Overall Level
SRI
EOY
Word Analysis Level
Lexile
Fluency Level
Vocabulary Level
Comprehension Level
Level
Month _______
It is the policy of San Antonio ISD not to discriminate on the basis of race, color, national origin, age, sex or handicap in its vocational programs, services or activities as required by Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972; and Section 504 of the
Rehabilitation Act of 1973, as amended.
Es norma del distrito de San Antonio no discriminar por motivos de raza, color, origen nacional, edad, sexo o impedimento, en sus programas, servicios o actividades vocacionales, tal como lo requieren el Título VI de la Ley de Deprechos Civiles de 1964, según enmienda; el Título IX de las Emmiendas en
la Educación, de 1972, y la Sección 504 de la Ley de Rehabilitación de 1973, según enmienda
Revised ELAR Department April 2015
Page 1 of 2
GPC Form B: Acceleration Instruction Plan after 1st Test Administration – Grade 5
Name: Jane Q. Student
ID Number: 00000001
Total Correct
1st
Administration
Areas of
Acceleration
Category 1
18 of 46
Category 2
Category 3
_4_of 10
8_ of 19
_6_ of 17



DURATION
Daily during 10 day(s) to implement a targeted Accelerated Instruction Plan. Daily instruction will be
1 hour per day
 2 hours per day
3 hours per day
6 hours per day
Other: ___________
May Acceleration Instruction Prior to 2nd Test Administration (AIP)
Day 1
Day 2
Day 3
Assessment
Results
3/5
Assessment
Results
4/5
TEK Focus
5.11A, Fig.
19D
TEK Focus
5.11A,
5.11D
Close
Reading
Strategy
Close
Reading,
Hot Seat
Strategy
Day 6
Day 4
2/5
Assessm
ent
Results
Day 5
Assessme
nt Results
5/5
Assessment
Results
4/5
TEK
Focus
5.11C, 5.10A
TEK
Focus
5.11C, 5.10A
TEK Focus
5.11D,
5.13B
Strategy
Text
Organization
It Says, I Say
Strategy
Text
Organization
It Says, I Say
Strategy
Interpreting
Text
Features
Day 7
Day 8
Day 9
Day 10
Assessment
Results
3/5
Assessment
Results
4/5
Assessment
Results
4/5
Assessment
Results
4/5
Assessment
Results
3/5
TEK Focus
5.3A,
Fig.19F
TEK Focus
5.3A,
Fig.19F
TEK Focus
5.6A,
Fig.19E
TEK Focus
5.6B,
Fig.19D
TEK Focus
5.4A, 5.8A,
Fig.19D
Strategy
Paired
Passage
Process
Strategy
Paired
Passage
Process
Strategy
Reading
Comp.
Process,
Somebody
- Wanted
Strategy
Inferring
Character
Feelings
Strategy
It Says, I
Say, and So
Date
Time
4/20/15
1:15 PM
Complete
Admin
Initials

DJ



DJ
DJ
DJ
Parent / Guardian Contact
Person Contacted
Jane Doe (mother)
Summary of Discussion
Discussed results and the planned intervention
Attached Documentation
Please check the complete box to indicate any documentation included and initial to verify that you have
included the documentation.
Form R.2 (Notification of Student Performance-Not meet passing standard)/ R.2 Spanish (Notification of Student
Performance- Not meet passing standard)
CSR (Confidential Student Report)
Teacher Notes/Observations
I Station Reports / SRI
Other
Principal / Designee Approval of AIP
Signature
Debra Jones (must be actual signature)
ItPosition
is the policy of San Antonio ISD not
to discriminate on the basis of race, color, national origin, age, sex or handicap in its vocational programs, services or activities as required by Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972; and Section 504 of the
Principal
Rehabilitation Act of 1973, as amended.
Date
4/20/15
Es norma del distrito de San Antonio no discriminar por motivos de raza, color, origen nacional, edad, sexo o impedimento, en sus programas, servicios o actividades vocacionales, tal como lo requieren el Título VI de la Ley de Deprechos Civiles de 1964, según enmienda; el Título IX de las Emmiendas en
la Educación, de 1972, y la Sección 504 de la Ley de Rehabilitación de 1973, según enmienda
Revised ELAR Department April 2015
Page 2 of 2
GPC Form C: Acceleration Instruction Plan after 2nd Test Administration – Grade 5
Name: Jane Q. Student
2nd
Administration
Area of
Acceleration
ID Number: 00000001
Total Correct
Category 1
Category 2
Category 3
21 of 46
6 of 10
8 of 19
7 of 17


Use the Strategy Menu and Targeted Tested TEKS to Complete AIP
Summer School Intervention (AIP)
Day 1
Day 2
Day 3
Day 4
Day 5
Assessment
Results
3/5
Assessment
Results
3/5
Assessment
Results
4/5
Assessment
Results
3/5
Assessment
Results
5/5
TEK Focus
5.3, 5.4A, 5.6,
Fig.19E
TEK Focus
5.3, 5.4A, 5.6,
Fig.19
TEK Focus
5.3, 5.4A, 5.5A,
Fig.19D, E, F
TEK Focus
5.4A, 5.14,
Fig.19, Fig.19E
TEK Focus
5.4A, 5.11,
5.11A, 5.11B,
Fig.19D,
Fig.19E
Strategy
Mental Images,
SomebodyWanted, Hot
Seat, Look
Again
Strategy
It Says, I Say,
and So,
Inferences
Through Ads,
The Sherlock
Method, Plot
Diagram, Look
Again
Strategy
SomebodyWanted, TicTac-Toe, Paired
Passage
Process
Strategy
Reporter’s
Formula, Hot
Seat, Read and
Retell
Strategy
Reporter’s
Formula, Hot
Seat, Read and
Retell
Date
6/4/15
Complete
Parent / Guardian Contact
Person Contacted
Time
2:30 PM
Admin.
Initials

DJ

DJ

DJ

DJ

DJ


DJ
DJ
Printed Name
Debra Jones
Jane Doe (mother)
Summary of Discussion
Discussed results and how we will address the student’s needs until the
end of the year. Summer School application has been signed.
Attached Documentation
Please check the complete box to indicate any documentation included and initial to verify that you have included the
documentation.
Form R.3 (Notification of Student Performance-Did not meet passing standard, Second Administration)/ Form R.3
Spanish (Notification of Student Performance-Did not meet passing standard, Second Administration)
Form R.4 (Confirmation of Participation in the GPC Meeting-Second Administration)/ Form R.4 Spanish (Confirmation
of Participation in the GPC Meeting-Second Administration)
Form R.5 (GPC Meeting Minutes Second Administration)/Form R.5 Spanish (GPC Meeting Minutes Second
Administration)
Form R.6 (Parent Notification of GPC decision- Second Administration)/ Form R.6 Spanish (Parent Notification of GPC
decision- Second Administration)
Form R.7 (Parent Waives Right to Third Administration)/ Form R.7 Spanish (Parent Waives Right to Third
Administration) If Applicable
CSR (Confidential Student Report)
Summer School Application
Other
Grade Placement Committee Members:
Relationship
Principal/Principal Designee
Signature
Debra Jones
Date
6/1/15
Jane Doe
Parent/Guardian
Jane Doe
6/1/15
Juan Doe
Parent/Guardian
Juan Doe
6/1/15
Melanie Wilson
Reading Teacher
Melanie Wilson
6/1/15
Other
(must be original signatures )
Other
It is the policy of San Antonio ISD not to discriminate on the basis of race, color, national origin, age, sex or handicap in its vocational programs, services or activities as required by Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972; and Section 504 of the
Rehabilitation Act of 1973, as amended.
Es norma del distrito de San Antonio no discriminar por motivos de raza, color, origen nacional, edad, sexo o impedimento, en sus programas, servicios o actividades vocacionales, tal como lo requieren el Título VI de la Ley de Deprechos Civiles de 1964, según enmienda; el Título IX de las Emmiendas en
la Educación, de 1972, y la Sección 504 de la Ley de Rehabilitación de 1973, según enmienda
Revised ELAR Department April 2015
GPC Form D: Accelerated Instruction Plan after 3rd Administration: First Six Weeks of School – Grade 5
Name: Jane Q. Student
3rd
Administration
Area of
Acceleration
ID Number: 00000001
Total Correct
Category 1
Category 2
Category 3
29 of 46
8 of 10
12 of 19
9 of 17



Duration
Daily during _____ day(s) period to implement a targeted Accelerated Instruction Plan. Daily instruction will be
1 hour per day
2 hours per day
3 hours per day
6 hours per day
 Other: 45 minutes per day
Intervention Plan
Accelerated Instruction Plan: First Six Weeks of School (AIP)
Week 1
Assessment Results
Assessment Results
Assessment Results
5.6B, 5.8A
TEK Focus
Week 4
Fig. 19D, Fig.19E
TEK Focus
Week 5
Week 6
Assessment Results
5.10A, 5.11A, 5.11B
TEK Focus
Week 3
Assessment Results
5.2B, 5.3C
TEK Focus
Week 2
Assessment Results
5.12A, 5.12B, 5.14C
TEK Focus
Fig. 19D, Fig. 19E
TEK Focus
Parent/Guardian Contact
Date
Time
Person Contacted
Summary of Discussion
7/21/15
3:30 PM
Jane Doe
Discussed the results and invitation to GPC
Attached Documentation
Complete
Admin.
Initials

DJ

DJ

DJ
DJ


DJ
DJ

Please check the complete box to indicate any documentation included and initial to verify that you have included the
documentation.
Form R.8 (Notification of Student Performance-Did not meet passing standard, Third Administration)/ R.8 Spanish (Notification of
Student Performance-Did not meet passing standard, Third Administration)
Form R.9 (Confirmation of Participation in the GPC Meeting-Second Administration)/ Form R.9 Spanish (Confirmation of Participation
in the GPC Meeting-Third Administration)
Form R.10 (GPC Meeting Minutes Third Administration)/Form R.10 Spanish (GPC Meeting Minutes Third Administration)
Form R.11 (Parent Notification of GPC decision- Third Administration)/ Form R.11 Spanish (Parent Notification of GPC decisionThird Administration)
CSR (Confidential Student Report)
Other: Work Samples
It is the policy of San Antonio ISD not to discriminate on the basis of race, color, national origin, age, sex or handicap in its vocational programs, services or activities as required by Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972; and Section 504 of the
Rehabilitation Act of 1973, as amended.
Es norma del distrito de San Antonio no discriminar por motivos de raza, color, origen nacional, edad, sexo o impedimento, en sus programas, servicios o actividades vocacionales, tal como lo requieren el Título VI de la Ley de Deprechos Civiles de 1964, según enmienda; el Título IX de las Emmiendas en
la Educación, de 1972, y la Sección 504 de la Ley de Rehabilitación de 1973, según enmienda
Revised ELAR Department April 2015
Page 1 of 2
Printed Name
Debra Jones
Grade Placement Committee
Signature
Relationship
Jane Doe
Juan Doe
Melanie Wilson
Principal / Principal Designee
Debra Jones
Date
7/11/15
Parent / Guardian
Jane Doe
7/11/15
Parent / Guardian
Juan Doe
7/11/15
Reading Teacher
Melanie Wilson
7/11/15
Agree
Disagree




(must be original signatures )
Other
Other
Review of AIP by Receiving Campus
Printed Name
Role
Signature
Date
Walter Winchell
7/11/15
Assigned Teacher
Johnny Rocket
7/11/15
Other Counselor
John Grisham
7/11/15
Walter Winchell
Principal / Designee
Johnny Rocket
John Grisham
Other
(must be original signatures )
It is the policy of San Antonio ISD not to discriminate on the basis of race, color, national origin, age, sex or handicap in its vocational programs, services or activities as required by Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972; and Section 504 of the
Rehabilitation Act of 1973, as amended.
Es norma del distrito de San Antonio no discriminar por motivos de raza, color, origen nacional, edad, sexo o impedimento, en sus programas, servicios o actividades vocacionales, tal como lo requieren el Título VI de la Ley de Deprechos Civiles de 1964, según enmienda; el Título IX de las Emmiendas en
la Educación, de 1972, y la Sección 504 de la Ley de Rehabilitación de 1973, según enmienda
Revised ELAR Department April 2015
Page 2 of 2