Diocese of Buffalo
Academic Intervention Services (AIS)
Definition:
Supplemental periods of
instruction
Supplemental in-class support
Monitoring student academic progress
Monitoring support services for non-academic barriers to learning
This form is to be used for tracking and documenting students that qualify
for Academic Intervention Services:
 |
Student’s name and ID number
________________________ |
|
Grade level of the student
____________________________ |
|
Disability (if any)
____________________________________ |
|
Type of service(s) being provided
to each student ___________________________________________________ |
|
Provider of the service
________________________________ |
|
Date written notification was
sent to parent/guardian that AIS is needed
_____________________________________________ |
|
Start date for AIS
____________________________________ |
|
Reason why AIS is needed
_____________________________ |
|
Assessment(s) used to determine
AIS ____________________ |
|
Frequency the student meets for
AIS ____________________ |
|
Duration the student will meet
for AIS ___________________ |
|
Anticipated end date for AIS
___________________________ |
|
Reason(s) why AIS is ending
___________________________ |
___________________________________________________
|
Date written notification was
sent to parent/guardian that AIS is being terminated
_____________________________________ |
Principal's Signature Date
[Diocese of Buffalo]. All rights reserved.
This page was last updated on 10/25/01.
