Preview Student Action Plan Form

!Action'Plan'Form'

Problem'

Specific'Activities'

(student'fills'in'th is'se ctio n'with'

activities/strategies'planned'to'

help'reach'expected'outcome)'

Outcome'Measurement'(what'CI,'

student'must'see,'hear,'feel'to'

achieve'the'expected'outcome'and'

verify'accomplishment)'

Consequences'for'unsuccessful'completion:'

Learning Objective should be:

1. Specific

2. Measurable

3. Achievable

4. Results centered

5. Time bounded

!At!completion!of!the!time!frame:!

Student!signature! __________________________________!

CI!signature! ! __________________________________!

Date! ! ! __________________________________!

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