Functional Behavioral Assessment Worksheet

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Student Name (DOB) _________________________________________ Grade ________ Today’s Date _________

School District/Building __________________________________________________________ FBA Team Members

_____________________________________________________ _____________________________________________________

Indirect Direct

___ Record Review ___ Consultant Observation

___ Behavior Logs/ Discipline Reports ___ ABC Data Collection

___ Structured Interviews w/__________________ ___ Staff Direct Observation

___ Reports from ___________________________ ___ Other Direct Data Collection_____________

Rating Scales ___________________________

Tasks for completing an FBA Who? By when?

1. Obtain parental permission (if applicable)

2. Records Review

 Academic

 Medical

 Discipline (SWIS) 3. Schedule/ conduct interviews (teachers/ staff)

4. Schedule / conduct interviews with student and parents (if necessary)

5. Schedule / conduct observation

 ABC

 Scatter plot

6. Summarize data and develop hypothesis statement

7. Develop Behavior Support Plan 8. Evaluate Plan.

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Functional Behavioral Assessment Student-Assisted Interview Form

Interviewer:___ ________ Date___________

Respondent__

1. Tell me about things that you like/ dislike at school, home, and other places.

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________

2. Tell me about things that seem to be going well or not so well at school, home, and other places.

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________

3. Tell me about the subject or class you like most or least. Why?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________

4. Tell me about when you seem to have the most or least problems (where you are; what time of day; who else is around you).

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________

5. Tell me what happens when you [target behavior]. What does the teacher say or do. What do the other students say or do?

______________________________________________________________________________

__________________________________________________________________________________________ ____________________________

6. Do you remember what were you thinking right before you [target behavior]?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________

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Functional Behavioral Assessment

Teacher Interview Form

Interviewer(s)_________________________________________Date(s)_______________________________ Student(s)_________________________________________________________________________________ Respondent(s)___________________________________________

1. Describe the behavior of Concern

__________________________________________________________________________________________ __________________________________________________________________________________________ ___________________________________________________________________________________

2. How often does the behavior occur?

________________________________________________________________

__________________________________________________________________________________________ __________________________________________________________________________________________

How long does it last?

__________________________________________________________________________________________ ____________________________________________________________________________________

How intense is the behavior?

__________________________________________________________________________________________ ______________________________________________________________________________

3. What is happening when the behavior occurs?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 4. When/where is the behavior most/least likely to occur?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________________________

5. With whom is the behavior most/least likely to occur?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________________________

6. What conditions are most likely to precipitate (“set off ”) the behavior?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________

7. How can you tell the behavior is about to start?

__________________________________________________________________________________________ __________________________________________________________________________________________

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__________________________________________________________________________________________ ____________________________________________________________________________

8. What usually happens after the behavior? Describe what happens according to adult(s), peers, and student responses. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________

9. What is the likely function (intent) of the behavior; that is, why do you think the student behaves this way?

What does the student get or avoid?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ______________________________________________________________________________________ 10. What behavior(s) might serve the same function (see question 9) for the student that is appropriate within the social/environmental context?

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 11. What other information might contribute to creating an effective behavioral intervention plan (e.g., under what conditions does the behavior not occur?)

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _____________________________________________________________________________

12. Who should be involved in the planning and implementation of the behavioral intervention plan? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________

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Functional Assessment Checklist for Teachers and Staff (FACTS-Part A)

Student/ Grade: ______________________________ Date: ____________________________

Student Profile: Please identify at least three strengths or contributions the student brings to school. ___________________________________________________________________________________ ___________________________________________________________________________________

Problem Behavior(s): Identify problem behaviors

___ Tardy ___ Fight/physical Aggression ___ Disruptive ___ Theft ___ Unresponsive ___ Inappropriate Language ___ Insubordination ___ Vandalism

___ Withdrawn ___ Verbal Harassment ___ Work not done ___ Other ________________ ___ Verbally Inappropriate ___ Self-injury

Describe problem behavior: ____________________________________________________________

Identifying Routines: Where, When and With Whom Problem Behaviors are Most Likely.

Schedule (Times)

Activity Likelihood of Problem Behavior Specific Problem Behavior Low High 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6

Select 1-3 Routines for further assessment: Select routines based on (a) similarity of activities (conditions) with ratings of 4, 5 or 6 and (b) similarity of problem behavior(s). Complete the FACTS-Part B for each routine identified.

March, Horner, Lewis-Palmer, Brown , Crone, Todd & Carr (2000) 4/24/00

Step 1

Step 2

Step 3

Step 4

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Functional Assessment Checklist for Teachers & Staff (FACTS-Part B)

Student/ Grade: ______________________________ Date: ____________________________ Interviewer: _________________________________ Respondent(s): ____________________

Routine/Activities/Context: Which routine(only one) from the FACTS-Part A is assessed?

Routine/Activities/Context Problem Behavior(s)

Provide more detail about the problem behavior(s):

What does the problem behavior(s) look like? How often does the problem behavior(s) occur?

How long does the problem behavior(s) last when it does occur? What is the intensity/level of danger of the problem behavior(s)?

What are the events that predict when the problem behavior(s) will occur? (Predictors) Related Issues (setting events)

Environmental Features ___ illness Other:_________________ ___ drug use ______________________ ___ negative social ______________________ ___ conflict at home ______________________ ___ academic failure ______________________

___ reprimand/correction ___ structured activity

___ physical demands ___ unstructured time ___ socially isolated ___ tasks too boring

___ with peers ___ activity too long

___ Other ___ tasks too difficult __________________

What consequences appear most likely to maintain the problem behavior(s)? Things that are Obtained

Things Avoided or Escaped From ___ adult attention Other: ________________

___ peer attention ______________________ ___ preferred activity ______________________ ___ money/things ______________________

___ hard tasks Other: ___________________ ___ reprimands ________________________ ___ peer negatives ________________________

___ physical effort ________________________

___ adult attention ________________________ SUMMARY OF BEHAVIOR

Identify the summary that will be used to build a plan of behavior support. Setting Events & Predictors Problem Behavior(s) Maintaining Consequence(s)

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6

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How confident are you that the Summary of Behavior is accurate?

Not very confident Very Confident

1 2 3 4 5 6

What current efforts have been used to control the problem behavior? Strategies for preventing problem behavior

Strategies for responding to problem behavior

___ schedule change Other: ________________ ___ seating change ______________________ ___ curriculum change ______________________

___ reprimand Other: ___________________ ___ office referral _________________________ ___ detention _________________________

March, Horner, Lewis-Palmer, Brown , Crone, Todd, & Carr (2000) 4/24/00 Step 7

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The Functional Assessment Checklist for Teachers and Staff (FACTS): Instructions

The FACTS is a two-page interview used by school personnel who are building behavior support plans. The FACTS is intended to be an efficient strategy for initial functional behavioral assessment. The FACTS is completed by people (teachers, family, clinicians) who know the student best, and used to either build behavior support plans, or guide more complete functional assessment efforts. The FACTS can be completed in a short period of time (5-15 min). Efficiency and

effectiveness in completing the forms increases with practice.

How to Complete the FACTS-Part A

Step #1: Complete Demographic Information:

Indicate the name and grade of the student, the date the assessment data were collected, the name of the person completing the form (the interviewer), and the name(s) of the people providing information (respondents).

Step #2: Complete Student Profile

Begin each assessment with a review of the positive, and contributing characteristics the student brings to school. Identify at least three strengths or contributions the student offers.

Step #3: Identify Problem Behaviors

Identify the specific student behaviors that are barriers to effective education, disrupt the education of others, interfere with social development or compromise safety at school. Provide a brief description of exactly how the student engages in these behaviors. What makes his/her way of doing these behaviors unique? Identify the most problematic behaviors, but also identify any problem behaviors that occur regularly.

Step #4: Identify Where, When and With Whom the Problem Behaviors are Most Likely

A: List the times that define the student’s daily schedule. Include times between classes, lunch, before school and adapt for complex schedule features (e.g. odd/even days) if appropriate.

B: For each time listed indicate the activity typically engaged in during that time (e.g. small group instruction, math, independent art, transition).

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C: Use the 1 to 6 scale to indicate (in general) which times/activities are most and least likely to be associated with problem behaviors. A “1” indicates low likelihood of problems, and a “6” indicates high likelihood of problem behaviors.

D: Indicate which problem behavior is most likely in any time/activity that is given a rating of 4, 5 or 6.

Step #5: Select Routines for Further Assessment

Examine each time/activity listed as 4, 5 or 6 in the Table from Step #4. If activities are similar (e.g. activities that are unstructured; activities that involve high academic demands; activities with teacher reprimands; activities with peer taunting) and have similar problem behaviors treat them as “routines for future analysis”.

Select between 1 and 3 routines for further analysis. Write the name of the routine, and the most common problem behavior(s). Within each routine identify the problem behavior(s) that are most likely or most problematic.

For each routine identify in Step #5 complete a FACTS-Part B

How to Complete the FACTS-Part B

Step #1: Complete Demographic Information:

Identify the name and grade of the student, the date that the FACTS-Part B was completed, who completed the form, and who provided information for completing the form.

Step #2: Identify the Target Routine

List the targeted routine and problem behavior from the bottom of the FACTS-Part A. The FACTS-Part B provides information about ONE routine. Use multiple Part B forms if multiple routines are identified.

Step #3: Provide Specifics about the Problem Behavior(s)

Provide more detail about the features of the problem behavior(s). Focus specifically on the unique and distinguishing features, and the way the behavior(s) is disruptive or dangerous.

Step #4: Identify Events that Predict Occurrence of the Problem Behavior(s)

Within each routine what (a) setting events, and (b) immediate preceding events predict when the problem behavior(s) will occur. What would you do to make the problem behaviors happen in this routine?

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Step #5: Identify the Consequences that May Maintain the Problem Behavior

What consequences appear to reward the problem behavior? Consider that the student may get/obtain something they want, or that they may escape/avoid something they find unpleasant.

Identify the most powerful maintaining consequence with a “1”, and other possible consequences with a “2” or “3.” Do not check more than three options. The focus here, is on the consequence that has the greatest impact.

When problems involve minor events that escalate into very difficult events, separate the consequences that maintain the minor problem behavior from the events that may maintain problem behavior later in the escalation.

Step #6: Build a Summary Statement

The summary statement indicates the setting events, immediate predictors, problem behaviors, and maintaining consequences. The summary statement is the foundation for building an effective behavior support plan. Build the summary statement from the information in the FACTS-A and FACTS-B (Especially the information in Steps #3, #4, and #5 of the FACTS-B). If you are confident that the summary statement is accurate enough to design a plan move into plan development. If you are less confident, then continue the functional assessment by conducting direct observation.

Procedures for completing the functional assessment, and for designing behavioral support are described in the following references.

Step #7: Determine “Level of Confidence”

Use the 1-6 scale to define the extent to which you, the interviewer or the team are “confident” that the summary statement is accurate. Confidence may be affected by factors such as (a) how often the problem behavior occurs, (b) how long you have known the focus person, (c) how consistent the problem behaviors are, (d) if multiple functions are identified, and (e) if multiple behaviors occur together

Step #8: Define what has been done to date to prevent/control the problem behavior

In most cases, school personnel will have tried some strategies already. List events that have been tried, and organize these by (a) those things that have been to prevent the problem from getting started, (b) those things that were delivered as consequences to control or punish the problem behavior (or reward alternative behavior).

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ABC OBSERVATION FORM

Student Name: _______________ Observation Date:________

Observer: __________________ Time: _________________

Activity: ___________________ Class Period: ____________

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Student: _____________________ Observer: ______________________

Date: ______________ Time: ___________ Activity: _______________

_______________________________________________________________ Context of Incident: Antecedent: Behavior: Consequence: Comments/Other Observations:

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Student Name: Ben S._______ Observation Date: 10/5____

Observer: R. Day____________ Time: 9:40-9:55 a.m.______

Activity: disruptive behavior____ Class Period: 3__________

ANTECEDENT BEHAVIOR CONSEQUENCE

Teacher begins – tells students to look at board.

Ben looks around room and at other kids.

Teacher continues lesson; ignores Ben.

Teacher puts examples on board and asks class to work problems.

Ben looks around and calls to Fran.

Teacher asks for quiet.

Teacher tells class to do 5 more problems. Ben turns around and pokes Fran with pencil.

Teacher tells Ben, “get to work, NOW!”

Ben calls out, “this is too hard.” He throws

worksheet and book on floor.

Teacher demands that Ben come forward, get a hall pass, and go to the office.

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APPENDIX B

ABC OBSERVATION FORM

Student Name: Trish________________ Observation Date: 10/5__

Observer: Ms. Pasillas________________ Time: 9:40-9:55 a.m.____

Activity: disruptive behavior on the playground Class Period: 3_________

ANTECEDENT BEHAVIOR CONSEQUENCE

Trish joins group of 4 girls playing catch.

Trish waits for ball to be thrown to her.

Girls do not throw ball to Trish. Trish yells “Throw it to

me!”

Girls throw ball to her, she misses it and another girl, LuAnne catches it and throws it to Sandy.

Ball is again thrown to Karen. Trish yells “ I said throw

it to me you jerk!” Karen begins to walk away with the ball. Trish runs up behind

Karen and kicks her saying “Give it to me damn it!”

Karen cries. Trish takes the ball.

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APEX II Functional Behavioral Assessment

FUNCTIONAL ASSESSMENT SCATTERPLOT

Student: _______________________________ Grade: ________ School:

______________________________

Date(s): _______________________________

Observer(s):_________________________________________ Behavior(s) of concern:

________________________________________________________________________

ACTIVITY TIME DAY OF

THE WEEK

TOTAL

Monday Tuesday Wednesday Thursday Friday

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FUNCTIONAL ASSESSMENT SCATTERPLOT

Student: Myree Grade: 6th School: John B.

Lynn

Date(s): 10/4/97 to 10/8/97 Observer(s): Dennis

Behavior(s) of concern: disrupts class w/inappropriate comments and verbal threats directed at peers.

Setting:

__________________________________________________________________________________

ACTIVITY TIME

DAY OF

THE WEEK _TOTAL

Monday Tuesday Wednesday Thursday Friday

MATH 9:20-10:10

II IIII III II IIII 15

SCIENCE 10:10-11:00 I II I I II 7 SOCIAL STUDIES 11:00-11:50

II IIII IIII I IIII 15

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PROBLEM BEHAVIOR QUESTIONNAIRE

Student ____________________________ Teacher _______________________ Date ________________

Student Behavior: Keeping in mind the problem behaviors identified in the Teacher Interview. Circle the frequency

at which each of the following statements is true.

Never 10% of 25% of 50% of 75% of 90% of Always time time time time time

1. Does the problem behavior occur and persist

when you make a request to perform a task? 0 1 2 3 4 5 6

2. When the problem behavior occurs, do you redirect the student to get back to task or

follow the rules? 0 1 2 3 4 5 6

3. During a conflict with peers, if the student engages in the problem behavior, do peers

leave the student alone? 0 1 2 3 4 5 6

4. When the problem behavior occurs, do peers

verbally respond or laugh at the student? 0 1 2 3 4 5 6

5. Is the problem behavior more likely to occur following a conflict outside the classroom?

(e.g. bus write-up) 0 1 2 3 4 5 6

6. Does the problem behavior occur to get your attention when you are working with another

student? 0 1 2 3 4 5 6

7. Does the problem behavior occur in the

presence of specific peers? 0 1 2 3 4 5 6

8. Is the problem behavior more likely to continue to occur throughout the day following an earlier

episode? 0 1 2 3 4 5 6

9. Does the problem behavior occur during specific

academic activities? 0 1 2 3 4 5 6

10. Does the problem behavior stop when peers

stop interacting with the student? 0 1 2 3 4 5 6

11. Does the behavior occur when peers are

attending to other students? 0 1 2 3 4 5 6

12. If the student engages in the problem behavior, do you provided one-to-one instruction to get

the student back on task? 0 1 2 3 4 5 6

13. Will the student stop doing the problem behavior if you stop making requests or end an

academic activity? 0 1 2 3 4 5 6

14. If the student engages in the problem behavior,

do peers stop interacting with the student? 0 1 2 3 4 5 6

15. Is the problem behavior more likely to occur following unscheduled events or disruption in

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Student _____________________

Problem Behavior Questionnaire Profile

Peers Peers Adults Adults Setting Events Escape Attention Escape Attention______________________ Question: 3 10 14 4 7 11 1 9 13 2 6 12 5 8 15 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Developed by Lewis, Timothy J., Scott, Terrance M., Sugai, George. (1994) Diagnostic, 19 (2-3), 1-3-115.

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FINAL REPORT

STUDENT ASSISTANCE TEAM XY HIGHSCHOOL

FUNCTIONAL ASSESSMENT OF BEHAVIOR DATE:

NAME: SCHOOL:

BIRTH DATE GRADE:

AGE: TEACHER:

PRIMARY LANGUAGE: EVALUATOR

REASON FOR REFERRAL

Name was referred to the evaluator by REFERRAL SOURCE. It is our hope that this evaluation will aid in determining the function of the following behavior problem: PROBLEM BEHAVIOR AS DEFINED BY REFERRAL SOURCE. From this assessment, a behavior intervention plan will be developed.

These behaviors have interfered with Name's achievement of his/her academic goals and have resulted in suspension/ failure from school. From this assessment a behavior intervention program will be developed by the SAT.

At the time of referral Name displayed the following behaviors: (list behaviors as identified by the referral source)

 

ASSESSMENT PROCEDURES

BACKGROUND INFORMATION

Data Collection Methods Used:

Indirect Direct

___ Record Review ___ Consultant Observation ___ Behavior Logs/ Discipline Reports ___ ABC Data Collection ___ Structured Interviews w/__________________ ___ Staff Direct Observation

___ Reports from ___________________________ ___ Other Direct Data Collection_____________ ___ Rating Scales ___________________________ ___________________________________

Name is an age-year-old, grade-grade-sex who attends School. She/He has attended School since Month, Year. School attendance has been attendance pattern.

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Behavioral History

From interviews (with) and record review it was learned that this behavior problem has previously been displayed. (Describe history of behavior problem).

Previous interventions attempted to help manage this behavior problem have included the following: (Describe prior interventions). The following intervention components appear to have some potential and should be considered when developing Name's behavior intervention plan: (Describe previously attempted interventions that were helpful). Alternatively, the following components appear do not appear to have been helpful and should be avoided: (Describe previously attempted interventions that were not helpful and should be avoided). From this behavioral history a tentative hypothesis of the function(s) of the problem behavior was (were) developed. It would appear that this behavior is positively- and/or negatively reinforcing. Specifically, because of (Behavior problem) Name appears to obtain (List what the behavior gets for the student). and/or Specifically, because of (Behavior problem) Name appears to escape or avoid (Report what the behavior allows the student

Hypothesized Function of the Target Behavior

Based on this, what FUNCTION might the behavior be serving?(What is the student GETTING or AVOIDING by engaging in the behavior) INTERNAL EXTERNAL ACCESS / GET Something ___ Cognitive ________________________ ___ Emotional _______________________ ___ Communication ___ Control ___ Revenge ___ Sensory ___Auditory ___Visual ___ OTHER ___________________________ ___ Attention _________________________ ___ Tangibles ___ Activities _________________________ ___ Other ____________________________ AVOID/ESCAPE Something ___ Cognitive _________________________ ___ Emotional ________________________ ___ Physiological ______________________ ___ Sensory ___Auditory ___Visual ___ OTHER ___________________________ ___ Setting __________________________ ___ Task _____________________________ ___ Activity __________________________ ___ Person(s) _________________________ ___ Academic Subject __________________ ___ OTHER ___________________________ Replacement Behaviors

From interviews (with) it was determined that (State incompatible behavior) was a positive alternative behavior incompatible with the target behavior. Specifically, (Provide a clear behavioral description of the replacement behavior). This behavior would appear to obtain the same goal as the target behavior.

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PROBLEM IDENTIFICATION:

Describe the BEHAVIOR(s) of concern (observable and measurable):

_1.______________________________________________________________________________________________

_2.______________________________________________________________________________________________

_3.______________________________________________________________________________________________

Consequences of the Replacement Behavior

Currently, consequences of Name's (Replacement behavior) include (List the result or consequence of the replacement behavior for the student).

Potential reinforcers for the replacement behavior may include (From hypothesized function of behavior, list possible reinforcers that may increase the replacement behavior).

Consequences Maintaining the Behavior/FUNCTION:

What events typically FOLLOW the behavior? (See ABC Data)

_____________________________________________________________________________

_______________________________________________________________________________________________

Behavior Intensity (How severe is the behavior?)

This data helps to document the severity of the target behavior. At the time of this assessment, the behavior was rated as being a Level ? (On a scale of 1 to 5, with 5 being the most severe) on a disruptive behavior rating rubric. This level of behavioral severity is defined as follows: Level 1, Behavior is confined only to the observed student.

Level 2, Behavior disrupts others in the student’s immediate area. Level 3, Behavior disrupts everyone in the class.

Level 4, Behavior disrupts other classrooms or common areas of the school. Level 5, Behavior causes or threatens to cause physical injury to Name or others. Behavior Duration (How long does the behavior last?)

Duration data reflects the time that the behavior was expressed from beginning to end. For the purposes of baseline data collection, the behavior was judged to begin when Name (State beginning criteria) and to end when (State ending criteria). Data from each of the (state # of days) baseline data days was as follows:

Date Duration

During the data collection period Name displayed the behavior for a total (Total amount of time). On average the behavior lasted (Average).

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ESTABLISHING OPERATIONS THAT MAY INFLUENCE BEHAVIOR (SETTING EVENTS)

Also referred to as setting events or ecological variables, these events typically occur the morning of or evening before a given behavior is displayed. They make it more or less likely that a behavior will be judged as reinforcing (e.g., a student who is hungry will, find behaviors that obtain food more reinforcing). They also influence the likelihood that a behavior will occur (e.g., a student who is tired is more likely to display task avoidance behaviors). These events were identified by rating scales, observation, interview, and/or record review.

Antecedent / Setting Events (Contextual Variables):

What conditions tend to “SET OFF” the behavior (look for patterns in ABC Data)? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ For whom is the behavior a problem? _________________________

For whom is the behavior NOT a problem? ____________________

Where does the behavior occur MOST often? ________________________________ LEAST often? _______________________________

At what time of the day does the behavior occur MOST often?

______________________LEAST often? ___________________________

During what activities does the behavior occur MOST often?________________________ Least often?___________________________

Are the expectations for this student REASONABLE (describe)?

_____________________________________________________________

Are the adults in the student’s environment CONSISTENT (i.e: similar expectations, directions, discipline strategies. Please describe)

_______________________________________________________ Are the adults in the student’s environment RESPECTFUL of the student’s values/needs?________________________________________

Additional ANTECEDENTS / SETTING EVENTS Checklist (check/describe most relevant contextual variables) Medical/Emoti onal Environmental Social/ Interactional Curricular/ Instructional Personal ___ Hunger/Thirst ___ Auditory ___ Social Expectations

___ Task Difficulty

___Choice-Making

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w/ peers tion

___ Health ___ Transition ___ Teacher / Staff

___ Rate of Presentation ___Emotional ___ Medication ___ Predictability ___ Proximity ___ Delivery of Instruction ___Routine Dependent

___ Diet ___ Class Size ___ Behavior of

Peers

___ Level of Assistance ___Personal Likes/Dislikes

___ Sleep ___ Seating ___ Necessary

Social Skills ___ Meaningful ___Coping Skills ___ Clothing ___ Change of Staff ___ Variation of Material DESCRIBE: ______________________________________________________________________________ __________________________________________________________________ ________________________________________________________________________

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Behavior Support Plan, Summary Statement of the Problem

Behavior Pathway

SUMMARY

This assessment was designed to help determine the function of the following serious behavior problem: (Target Behavior). From this assessment it has been determined that the following events are establishing operations for this behavior: (List events). Immediate antecedents or triggers of the behavior appear to include (List Antecedents). The immediate consequences of Name’s behavior problem typically include (Consequences). Given this result of his/her behavior it is suggested that the problem behavior is negatively and/or positively reinforcing. In other words, when Name engages in (Target Behavior) he/she is likely to obtain (Positive Reinforcers) and/or escape and/or avoid (Negative Reinforcers).

Setting event Alternative Behavior Problem Behavior D esired Behavior Maintaining consequences Function Maintaining consequences

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RECOMMENDATIONS

(Try to avoid combining recommendations. Be specific in each recommendation. Use scripting for teachers when necessary. They should allow individuals not familiar with the student, the classroom, or even your assessment data to implement what you recommend)

From this functional assessment of behavior the following behavior intervention program recommendations are offered:

(Positive alternative behaviors)

List strategies that make the problem behaviors irrelevant, ineffective, & inefficient Predictor (setting event)

Strategies (how to modify the setting events)

e.g: Does not understand work.

Instructional Strategies e.g:

1. Pre teach work at beginning of class if there is available time. 2. Teacher report to Mentor or Guidance Counselor regularly on homework completion. Consequence Strategies 1.Take a moment after/before class to thank Johnny for doing work. 2. Be sure to thank Johnny if he asks for help with work.

Behavior Modifications (replace problem behaviors)

e.g: Blows up at teacher

1. Say to Johnny, your behavior right now is inappropriate. Then give him the option to either take walk to the drink fountain and return within 2 minutes (If you are not back by then, you will be reported to the office) or to calm down and return to his seat. 2. If refuses to cooperate, follow standard classroom discipline procedure for expressed behavior. 1. If Johnny speaks with the teacher after class, thank him for taking the time to calm down and speak about the matter. 2. If Johnny goes a week resolving disputes with teachers in a reasonable manner, then notify Mentor/Guidance to reward him with drink/snack.

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QUALITYOFLIFEINTERVENTIONS

The following interventions are geared towards improving the student’s life outside school in his natural settings at home and social events. These types of interventions will ensure that NAME will have a consistent reinforcement pattern across the board.

Personal Modifications: (modifications the student can do at home and /or social settings in order to achieve the desired goals/ desired behaviors)

Check & Connect Monitoring Sheet

Month_______________ Student_____________________ ID_____________________ School_____________________________________ Monitor________________________ Chec k M T W T h F M T W T h F M T W T h F M T W T h F M T W T h F Hig h Risk For Mon th Tardy Skip Absent Behavi or Referr al Detent ion In school suspen sion Out of school suspen sion Failing Classe s / behin d in Credit s

_____ D’s ____F’s _____Classes Passed out of ______ Total. _____Credits earned out of _____ Total

Connect Basic

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Provided regular feedback

Discussed staying in school

Problem solved about risk

Intensive

Arranged for alternative to suspension Contracted for behavior or grades Communicated with parents Made special accommodations Participated in Community Service Participated in school sponsored activity Participated in social skills

group Worked with tutor or

mentor

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Family modification: (modifications that parents can do at home in order to achieve the desired goals/ desired behaviors)

__________________________________ _______________________________

Parent/Guardian SAT member

_________________________________ _______________________________

Other staff member involved General Education Teacher

_________________________________ Student

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Behavior Support Plan Review

Student ____________________________________ Grade ____________ School _____________________________________ Date _____________ SAT monitoring member____________________________________

1. Review each task on the BSP Implementation plan to identify whether all tasks are being implemented successfully – answer below under

REVIEW DATA

MODIFICATIONS TO THE BSP IMPLEMENTATION PLAN

Tasks Person Responsible By When Was task Completed consistently? Evaluation Decision Monitor, Modify, or Discontinue

Date & Time of the Next BSP Review meeting ________________________________

__________________________________ _______________________________

Parent/Guardian SAT member

_

_________________________________ _______________________________

Other staff member General Education Teacher

Data Collected

Scatter-plot, point card, etc.

Summary of the data

# of occurrences/ patterns/ points earned out of possible points)

Evaluation Decision

Goal Attained/ Reinforcement Earned

Is Plan Being Implemented?

Is Plan Making a Difference?