Site-Level Intervention Record | WUSD Attendance Toolkit

Student

StudentSchoolGradeDate concern identifiedStaff leadCurrent attendance rate (%)AbsencesTardies

1. Notice — what are we seeing?

2. Ask — what do we know?

Student contacted?

YesNo

Student perspective

Parent/guardian contacted?

YesNo

Family perspectiveRelevant staff input

3. Identify — what may be getting in the way?

Barrier screening — not a diagnostic assessment.

4. Intervene — what are we going to try?

Barrier	Intervention	Responsible staff	Start date

Attendance prior to intervention (%)GoalReview date

5. Monitor — what happened?

10–15 instructional day intervention cycle: baseline → intervention → monitor → review.

Monitoring period (from – to)Days present / days possibleTardiesAttendance rate for monitoring period (%)

Was the intervention implemented?

YesPartiallyNo

What worked?What remains unresolved?

6. Pre-referral decision

RESOLVED — attendance has stabilized; return to universal monitoringCONTINUE — intervention is working; continue targeted support and monitoringMODIFY — modify intervention and conduct another progress-monitoring cycleREFER TO SST / MTSS team — reasonable pre-referral interventions implemented and monitored; additional multidisciplinary support neededIMMEDIATE/URGENT REFERRAL — circumstances warrant escalation without completing the standard cycle

If referring: what barriers remain unresolved?What interventions have been attempted?What additional support is being requested from the team?Staff leadDate