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Parent Interview

Child’s Name: Age: Grade: Sex: ❑ Male ❑ Female

Birthdate: Birthplace: Languages Spoken at Home:

Home Address:City State Zip

School Child Currently Attends:

A. Child’s Developmental & Medical History

Name of Child’s Physician: Date of Last Physical Exam:

Please describe the child’s general health status:

1. To your knowledge does the child have any allergies? ❑ Yes ❑ No (If yes, specify):

2. If the child has had any of the following medical conditions, please indicate by checking the box:❑ Chronic Ear Infections ❑ Anemia ❑ Asthma❑ Seizures ❑ Measles (rubeola) ❑ Rubella❑ Mumps ❑ Chicken Pox ❑ Scarlet Fever❑ Diphtheria ❑ Rheumatic Fever ❑ Heart Problems❑ Swollen Glands ❑ Frequent Colds ❑ Tonsillitis❑ Head Injuries ❑ Convulsions ❑ Frequent Respiratory Infections❑ Other (specify):

3. Was there any observable changes in the child’s behavior after or other unusual behavior following any of theillness marked in #2? ❑ Yes ❑ No (If yes, specify):

4. Are there any medical issues about the child you believe are important? ❑ Yes ❑ No (If yes, explain):

5. Is the child currently on any medication? ❑ Yes ❑ No (If yes, explain and indicate dosage):

6. Does the child have any visual problems? ❑ Yes ❑ No (If yes, describe):

7. Does the child have any speech problems? ❑ Yes ❑ No (If yes, describe):

Adapted from: “Case History Form” created by the Learning Improvement Center, University of Louisville Kentucky, andSattler, J.M. (1990) Assessment of Children. San Diego: Author (pp. 434-438).

B. Psychological and Social History

1. Has the child had previous testing or psychological examinations? ❑ Yes ❑ No (If yes, give date, agency,and summary of the major results):

2. Please describe the kinds of activities in which the child engages in the neighborhood and in the home.

3. Have there been any unusual changes or events recently in the home? ❑ Yes ❑ No (If yes, explain):

4. Is there any evidence of emotional tension, fear, irritation or lack of confidence in the child? ❑ Yes ❑ No (Ifyes, please describe):

5. Do you have any significant problems with the child in terms of (check all that apply):

❑ tantrums? ❑ defiance?❑ excessive activity level? ❑ getting along with parents?❑ poor attention span? ❑ getting along with siblings?❑ impulsivity? ❑ getting along with teachers?❑ aggressiveness? ❑ getting along with playmates?❑ withdrawal? ❑ poor motor coordination?❑ low self-confidence? ❑ difficulty with speech or language?❑ low motivation? ❑ oversensitivity?❑ following directions? ❑ engaging in dangerous behavior to self or others?❑ eats poorly? ❑ is stubborn?❑ gives up easily? ❑ trouble going to sleep?❑ nightmares? ❑ is clumsy?❑ prefers to be alone? ❑ is shy or timid?❑ wets bed? ❑ more interested in things than in people?❑ bites nails? ❑ sucks thumb?❑ bangs head? ❑ rocks body?

C. Educational Concerns

Place a check next to any educational problem that your child currently exhibits:

❑ Has difficulty with reading ❑ Has difficulty with other subjects (describe):❑ Has difficulty with arithmetic❑ Has difficulty with spelling❑ Has difficulty with writing

1. What do you perceive to be your child’s educational strengths?

2. What do you perceive to be your child’s educational needs?

3. Does your child seem to be experiencing school problems? ❑ Yes ❑ No If yes, what is your opinionregarding the nature of the child’s problem(s)?

4. How do you believe these problems can be best addressed?

5. What is your goal for your child’s education?

6. What is your goal for your child’s future as an adult?

7. How do you believe school personnel can assist your child in meeting the goals you have for him or her asan adult?

D. Disciplinary Concerns

What disciplinary techniques do you usually use when your child behaves inappropriately? Please check thebox next to each technique that you usually use. There also is space for writing in any other disciplinary tech-niques that you use.

❑ Ignore problem behavior ❑ Tell child to sit on chair❑ Scold child ❑ Send child to his or her room❑ Spank child ❑ Take away some activity or food❑ Threaten child ❑ Don’t use any technique❑ Reason with child ❑ Other technique (describe):❑ Redirect child’s interest

What disciplinary techniques are usually effective?

With what type of problem(s)?

What disciplinary techniques are usually ineffective?

With what type of problem(s)?

What have you found to be the most satisfactory ways of helping your child?

E. Other Information

What are your child’s favorite activities?

1. 4.2. 5.3. 6.

What activities would your child like to engage in more often than he or she does at present?

1. 3.2. 4.

What activities does your child like least?

1. 3.2. 4.

Teacher FunctionalAssessment Interview

Teacher:Interviewer: Date:Student:Target Behavior:

1. Can you describe for me in your own words what the problem behavior seems to be?

2. Could you be a little more specific? (For example, when you say that the student disrupts the class, whatexactly does he/she do?)

3. Now I’m getting the picture. Tell me, does this behavior take place every day (period)?

4. (If no) Would you say it happens every week? Every other week?

5. Can you identify anything that seems to happen before this behavior?

6. Is there a pattern regarding when the behavior occurs (e.g., more often on Mondays, after lunch, duringwriting period)?

7. Let’s try to figure out what the student gains from this behavior. Can you recall what happens to the student(i.e., what do you do) after this behavior occurs?

8. Have you been able to notice what other students in the room do when this behavior takes place?

9. Is there anything else you can tell me about this behavior or this student?

Kerr, M.M., & Nelson, C.M. (1998). Strategies for Managing Behavior Problems in the Classroom, 3rd Edition. Columbus, Ohio:Merrill, p. 55.

Student Functional AssessmentInterview and Reinforcement Survey

Student: School:Date of Birth: Age: Grade: Date Completed:Interviewer:

Section A

Always Sometimes Never

1. In general, is your work too hard for you?

2. In general, is your work too easy for you?

3. When you ask for help appropriately, do youget it?

4. Do you think work periods for each subjectare too long?

5. Do you think work periods for each subjectare too short?

6. When you do seatwork, do you do betterwhen someone works with you?

7. Do you think people notice when you doa good job?

8. Do you think you get the points or rewardsyou deserve when you do good work?

9. Do you think you would do better in schoolif you received more rewards?

10. In general, do you find your work interesting?

11. Are there things in the classroom thatdistract you?

12. Is your work challenging enough for you?

From Worthington & Gargiulo, 1998

Section B

1. When do you think you have the fewest problems with in school?

Why do you not have problems during this/these time(s)?

Why do you have problems during this/these time(s)?

What changes could be made so that you have fewer problems with this behavior?

















target behavior 1

target behavior 2

target behavior 3

target behavior 4

target behavior 5


Section C

Rate how much you like the following subjects:

Not at All Fair Very Much

Reading 1 2 3Math 1 2 3Spelling 1 2 3Handwriting 1 2 3Science 1 2 3Social Studies 1 2 3English/Language 1 2 3Music 1 2 3Physical Education 1 2 3Art 1 2 3Other (specify: ) 1 2 3

Section D

What do you like and dislike about:

Like Dislike

Reading

Math

Spelling

Handwriting

Science

Social Studies

English/Language

Music

Physical Education

Art

Other (specify: )


Section E – Reinforcement Survey

Directions: To complete this survey, it is recommended that each question be read to the student in an informalmanner. While you should guard against pressuring a student to complete each statement, please besure to follow-up or clarify any vague responses.

For younger children, you may want to consider placing each item on cards and use them to play agame (using a generic game board). The items can be made less threatening in a game-like formatbecause you will be completing the statements along with the student.

Your primary goal of this survey is to determine those reinforcers that have the greatest potentialfor use in a plan for behavior support.

Part I: Sentence Completion

1. My favorite adult at school is:The things I like to do with this adult are:

2 My best friend at school is:Some things I like to do with my best friend at school are:

3. Some other friends I have at school are:Some things I like to do with them are:

4. When I do well in school, a person I’d like to know about it is:

5. When I do well in school, I wish my teacher would:

6. At school, I’d like to spend more time with:Some things I’d like to do with this person are:

7. One thing I’d really like to do more in school is:

8. When I have free time at school I like to:

9. I feel great in school when:

10. The person who likes me best at school is:I think this person likes me because:

11. I will do almost anything to keep from:

12. The kind of punishment at school that I hate most is:

13. I sure get mad at school when I can’t:

14. The thing that upsets my teacher the most is:

15. The thing that upsets me the most is:


16. Some things I like are (check all that apply):

Favorite Edible Reinforcers Favorite Tangible Items

❑ candy (specify ) ❑ stuffed animals❑ fruit (specify ) ❑ pencils, pens, crayons❑ drinks (specify ) ❑ paper (specify )❑ cereal (specify ) ❑ trucks, tractors❑ snacks (specify ) ❑ sports equipment (specify )❑ nuts (specify ) ❑ toys (specify )❑ vegetables (specify ) ❑ books (specify )❑ other (specify ) ❑ puzzles

Academic Reinforcers Social Reinforcers

❑ going to library ❑ teaching things to other people❑ having good work displayed ❑ being the teacher’s helper❑ getting good grades ❑ spending time with my friends❑ having parents praise good school work ❑ spending time with the teacher❑ giving reports ❑ spending time with the principal❑ making projects ❑ spending time with ❑ completing creative writing projects ❑ having class parties❑ earning teacher praise ❑ working with my friends in class❑ helping grade papers ❑ being a tutor❑ getting a good note home ❑ being a leader in the class❑ earning stickers, points, etc. ❑ other (specify )❑ other (specify ) ❑ other (specify )

Activity Reinforcers Recreation/Leisure Reinforcers

❑ coloring/drawing/painting ❑ listening to music❑ making things (specify ) ❑ singing❑ going on field trips ❑ playing a musical instrument❑ taking care of/playing with animals ❑ watching TV❑ going shopping ❑ cooking❑ eating out in a restaurant ❑ building models❑ going to movies ❑ woodworking/carpentry❑ spending time alone ❑ favorite sports (specify )❑ reading ❑ working with crafts❑ having free time in class ❑ other (specify )❑ having extra gym/recess time ❑ other (specify )❑ working on the computer ❑ other (specify )❑ other (specify ) ❑ other (specify )


School Situation Questionnaire

Name of child: Date:Name of person completing this form:

Does this child present any behavior problems for you in any of these situations? If yes, please indicate howsevere they are:

Situation Yes/No If Yes, how severe (circle one)(circle one) Mild Severe

While Arrivingat School Yes No 1 2 3 4 5 6 7 8 9

During IndividualDesk Work Yes No 1 2 3 4 5 6 7 8 9

During SmallGroup Activities Yes No 1 2 3 4 5 6 7 8 9

During Free PlayTime in Class Yes No 1 2 3 4 5 6 7 8 9

During Lecturesto the Class Yes No 1 2 3 4 5 6 7 8 9

At Recess Yes No 1 2 3 4 5 6 7 8 9

At Lunch Yes No 1 2 3 4 5 6 7 8 9

In the Hallway Yes No 1 2 3 4 5 6 7 8 9

In the Bathroom Yes No 1 2 3 4 5 6 7 8 9

On Field Trips Yes No 1 2 3 4 5 6 7 8 9

During Special Assemblies Yes No 1 2 3 4 5 6 7 8 9

On the Bus Yes No 1 2 3 4 5 6 7 8 9

Barkely, R.A., & Edelbrock, C. (1987). Assessing Situational Variation in Children’s Problem Behaviors: The Home and SchoolSituations Questionnaires in R.J. Prinz (Ed.), Advances in Behavioral Assessment of Children and Families, Volume 3, pp. 157-176,JAI Press.

Home Situation Questionnaire

Name of child: Date:Name of person completing this form:

Does this child present any behavior problems for you in any of these situations? If yes, please indicate howsevere they are:

Situation Yes/No If Yes, how severe (circle one)(circle one) Mild Severe

While Playing Alone Yes No 1 2 3 4 5 6 7 8 9

While Playing withOther Children Yes No 1 2 3 4 5 6 7 8 9

Mealtimes Yes No 1 2 3 4 5 6 7 8 9

Getting Dressed Yes No 1 2 3 4 5 6 7 8 9

Washing/Bathing Yes No 1 2 3 4 5 6 7 8 9

While You Are onthe Telephone Yes No 1 2 3 4 5 6 7 8 9

While WatchingTelevision Yes No 1 2 3 4 5 6 7 8 9

When Visitors Arein Your Home Yes No 1 2 3 4 5 6 7 8 9

When You AreVisiting Someone Else Yes No 1 2 3 4 5 6 7 8 9

In Supermarkets, Stores,Churches, Restaurants,Other Public Places Yes No 1 2 3 4 5 6 7 8 9

When Asked to DoChores at Home Yes No 1 2 3 4 5 6 7 8 9

At Bedtime Yes No 1 2 3 4 5 6 7 8 9

While in the Car Yes No 1 2 3 4 5 6 7 8 9

While with aBaby-sitter Yes No 1 2 3 4 5 6 7 8 9

When Father Is Home Yes No 1 2 3 4 5 6 7 8 9

When Asked to DoSchool Homework Yes No 1 2 3 4 5 6 7 8 9

Barkely, R.A., & Edelbrock, C. (1987). Assessing Situational Variation in Children’s Problem Behaviors: The Home and SchoolSituations Questionnaires in R.J. Prinz (Ed.), Advances in Behavioral Assessment of Children and Families, Volume 3, pp. 157-176,JAI Press.

ABC Analysis Data Sheet - Documentation of Observable Behavior

Student:

Describe the behavior:What exactly did thestudent do? Where andwith whom?

What was thestudent doingimmediatelybefore thebehavioroccurred?

Speculate on thecommunicative intent ofthe behavior: mood, illness,change, transition, control,discomfort, frustration, etc.

How longdid thebehaviorlast?

Staff responseto the student’sbehavior

Student’sresponseto the staff

Staff’sInitials

TimeDate

How Many Times Count Chart

Student:

Class or Time Period:

Describe behavior being monitored:

Cross out a number each time the behavior occurs on that day or during the particular class or time period.

25 25 25 25 25 25 25 25 25 25 25 2524 24 24 24 24 24 24 24 24 24 24 2423 23 23 23 23 23 23 23 23 23 23 2322 22 22 22 22 22 22 22 22 22 22 2221 21 21 21 21 21 21 21 21 21 21 2120 20 20 20 20 20 20 20 20 20 20 2019 19 19 19 19 19 19 19 19 19 19 1918 18 18 18 18 18 18 18 18 18 18 1817 17 17 17 17 17 17 17 17 17 17 1716 16 16 16 16 16 16 16 16 16 16 1615 15 15 15 15 15 15 15 15 15 15 1514 14 14 14 14 14 14 14 14 14 14 1413 13 13 13 13 13 13 13 13 13 13 1312 12 12 12 12 12 12 12 12 12 12 1211 11 11 11 11 11 11 11 11 11 11 1110 10 10 10 10 10 10 10 10 10 10 109 9 9 9 9 9 9 9 9 9 9 98 8 8 8 8 8 8 8 8 8 8 87 7 7 7 7 7 7 7 7 7 7 76 6 6 6 6 6 6 6 6 6 6 65 5 5 5 5 5 5 5 5 5 5 54 4 4 4 4 4 4 4 4 4 4 43 3 3 3 3 3 3 3 3 3 3 32 2 2 2 2 2 2 2 2 2 2 21 1 1 1 1 1 1 1 1 1 1 10 0 0 0 0 0 0 0 0 0 0 0

Dates: ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Adapted from Shae & Bauer (1986)

Scatter Plot Data Sheet

Based on the work of P. Touchette, R. MacDonald, and S. Langer (1985)

A scatter plot can help to identify the patterns of responding in natural settings. Severe problems often occur inshort bursts of responding alternating with periods of no responding. Line graphs illustrate this frequency well.The scatter plot will display not only a sense of frequency but also the periods during the day in which the behavioris emitted. Severe problem behavior presents only two important rates: zero and unacceptable. The scatter plot willdisplay the presence and absence of the target behavior over the course of the day. The visual patterns of the scatterplot easily lend themselves to interpretation.

Problem behaviors may be highly correlated to a time of day, the presence or absence of certain people, a socialsetting, a class of activities, a contingency of reinforcement, a physical environment, and combinations of theseand other variables. The scatter plot can assist in demonstrating the effects of altering variables as hypothesesregarding the student behavior are tested through changes of schedule, activities, instructors or other variables.

A grid needs to be designed that is practical for the purpose (see sample attached). The grid segments could behours, half-hours, quarter hours, or any time unit appropriate to the duration of the student’s schedule. Horizontalsegments represent successive days. A blank cell represents a zero rate. The filled cell represents a problem behav-ior occurring during the time segment. If the target behavior needs to be divided into low and high frequency, aslash can represent the presence of the behavior in low frequency with a filled cell representing high frequency.

When the target behavior occurs in other settings or at other times, the chart may be extended to include all wakinghours and can be used at home after school or on weekends. The important aspect of recording the frequency of thetarget behavior is to define or describe the behavior well. Different observers of the same behavior should be inagreement as to the occurrence of the behavior and if necessary, determining if the behavior was high or lowfrequency during the designated time period.

The scatter plot can be used as an assessment tool and as a means of documenting change in behavior. The scatterplot allows insights into patterns of responding not readily available in graphs of daily or weekly frequency. Thetool has minimal demands on staff and the visible display has valuable dividends.

Successive Days

Name: Starting Date:

Comments:

Scatter Plot Data Sheet

Ecological Analysis of SettingsWhere Behavior Occurs Most Frequently

Student: Date:

Physical Setting (noise, crowding, temperature):

Social Setting (interaction patterns, with and around student):

Activities (activities/curriculum match learner needs?):

Nature of Instruction (instructional methods and techniques match learner needs?):

Scheduling Factors (timing, sequencing, and transition issues):

Degree of Independence (reinforcement intervals appropriate to foster appropriate independence):

Degree of Participation (group size, location, and participation parameters):

Social Interaction (social communication needs match instruction and opportunities):

Degree of Choice (amount of choice making and negotiation present in environment):

Review of Data on Internal States ThatPotentially Influence Behavior

Student: Date:

Behavior intervention case manager:

Interviewees:

Staff member completing this section:

I. Identified Handicapping Condition

Educational handicapping condition(s):

Does this condition have known behavior features? ❑ Yes ❑ No

If yes, describe those the student exhibits:

II. Identified Health/Biological Conditions

Medical Diagnosis:

Does diagnosis have known behavioral features? ❑ Yes ❑ No

If yes, describe those the student exhibits:

Vision

Hearing

Review of Vision and Hearing

Date of Last Examand Source

Nature of anyProblems

List any AccommodationsRequired

III. Current Medication Summary

Medication(s)and Dosage(s)

AnticipatedBenefit

Possible BehavioralSide-Effects

Source of Information:Parent, Doctor, Physi-

cians Desk Reference, etc.

Note Recent Change(s) in Medication:

Potential Effect on Problem Behavior:

Behavior Pattern as Related to Medication:

Variation(s) in Behavior as a Result of Mediation Ingestion Time(s):

IV. Sleep Cycles and Diet

Current Sleep Pattern:

Potential Impact on Behavior:

Note Recent Change(s) and Potential Impact on Behavior:

Note any Special Dietary Requirements, Restrictions, or Food Allergies:

Potential Impact on Behavior:

V. Unusual Responses or Sensitivity to Environmental Stimuli

Stimuli Unusual Response Potential Impact on Behaviors

Tactile

Auditory

Visual

Movement

Vibration

Smell & Taste

VI. Periodic Precipitating Factors

Note periodically occurring events that have led to an increase in problem behavior:

Student Date Class Activity

# of Students Start Time Stop Time Total Time

Paper/Pencil

Listen/Lecture

Teacher/PupilDiscussion

Manipulatives

Games

Worksheets/book

TextbookStudent/StudentActivity

Media/Technology

Transition

Other

TOTAL

Gable, R., Hendrickson, J. M, and Sealander, K. (1998). Ecobehavioral Observation. Beyond Behavior, 8, 2, 25-27.

Ecobehavioral Observation

Hypothesis Building Worksheet

Student: Date:School:

Members Participating in the Assessment Data Review:

TargetBehavior(s)

(list in order of priority)Target Target Target Target Target

Behavior #1 Behavior #2 Behavior #3 Behavior #4 Behavior #5

1. What causes or motivatesthe behavior?

2. When does the behavioroccur?

3. How often does the behavioroccur (i.e., frequency)?

4. How long does the behaviorlast (i.e., duration)?

5. What does the behaviorlook like (i.e., topography)?

6. How intense is the behavior ❑ Mild ❑ Mild ❑ Mild ❑ Mild ❑ Mild(if applicable)? ❑ Moderate ❑ Moderate ❑ Moderate ❑ Moderate ❑ Moderate

❑ Severe ❑ Severe ❑ Severe ❑ Severe ❑ Severe

7. Approximately how long hasthe behavior been occurring?

TargetBehavior(s)



8. Are there any circumstances ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ Noin which this behavior Describe: Describe: Describe: Describe: Describe:usually/frequently occurs?

9. Does this behavior occur ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ Nomore often during certain Describe: Describe: Describe: Describe: Describe:times of the day?

10. Does the behavior occur ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ Noonly with certain people Describe: Describe: Describe: Describe: Describe:in the environment?

11. Does the behavior occur ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ Noonly during certain subjects? Describe: Describe: Describe: Describe: Describe:

12. Could the behavior be ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ Norelated to any skill Describe: Describe: Describe: Describe: Describe:deficit(s)?

13. Could the behavior be ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ Nosignaling some deprivation Describe: Describe: Describe: Describe: Describe:condition (e.g., thirst, hunger,lack of rest), any form ofdiscomfort (e.g., headaches,stomach aches, hearing/visiondifficulties), or be caused bymedical conditions?

TargetBehavior(s)



14. Do any other behaviors ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ Nooccur along with the Describe: Describe: Describe: Describe: Describe:behavior?

15. Are there any observable ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ Noevents that signal that the Describe: Describe: Describe: Describe: Describe:behavior is about to occur?

16. What are the consequenceswhen the behavior occurs?

17. What is the functional intentof the behavior (i.e., whatdoes the student gain fromengaging in the behavior)?

18. Describe replacementbehavior or functionalalternatives to the behavior.

Quality Assurance Rating Scale for Intervention Choices

1. The intervention should prove 1 2 3 4effective in reducing the student’sproblem.

2. The student’s problem is severe 1 2 3 4enough to warrant use of thisintervention.

3. This would be an acceptable 1 2 3 4intervention for the student fromthe parent, community, culture, andschool perspectives.

4. Considering all possible implications, 1 2 3 4the intervention would not result innegative side-effects.

5. The intervention is a fair way to 1 2 3 4handle this student’s problem.

6. The intervention would quickly 1 2 3 4improve the student’s situation.

7. The intervention would produce 1 2 3 4a lasting improvement in thestudent’s performance.

8. The intervention allows the student 1 2 3 4to be more independent.

9. The student’s behavior will remain 1 2 3 4at an improved level even after theintervention is discontinued.

10. Using the intervention will improve 1 2 3 4the student’s performance in theclassroom and in other settings(e.g., other classrooms, communitysites, home).

Strongly StronglyDisagree Disagree Agree Agree

Initial Planning for Academic and Behavior Support:30-Minute Collaboration

Student: Date:Participants:

Set timer for 10 minutes.Step 1: Describe current state:• Behavioral descriptions of the student’s functioning in area of concern. Ask,

“What does the student do?” and “What is the student not doing?”

Evaluate behaviors of concern:

1. Yes No Does the behavior threaten the life of the student or others?2. Yes No Does the behavior threaten the physical well being of the student

or others?3. Yes No Does the behavior interfere with the educational progress of the

student?4. Yes No Does the behavior interfere with the educational progress of

others?5. Yes No Does the behavior result in materials destruction or damage?6. Yes No Will the behavior become more serious without intervention now?7. Yes No Does the behavior interfere with acceptance by peers or adults?

Behavior strength:Learn how often, how long, and how intense the behavior is. For example, ask,“How often does the student hit?” “How long does the episode last?” “Howdisruptive is the student’s behavior?”

a. Frequency (How often?)b. Duration (How long?)c. Intensity (How much?)d. Is this unique or typical behavior for the student?

Location:Obtain a description of the setting. Ask, “Where does the student do this?”“Where else does the student do this?” “Where doesn’t the student do this?”

a. Specify examples of the behavior in the different settings.b. Prioritize by setting where the behavior occurs most frequently.

Time:When, during the day, does the student exhibit this behavior? When does thestudent not engage in this behavior?

F. Mueller permission granted to copy

Identify antecedent conditions:Identify events that immediately precede the target behavior. Ask, “What happensright before the student does this?” “What seems to trigger this behavior?”

Identify simultaneous conditions:Consider situational or environmental events that may contribute to the behaviorproblem. Ask, “What else is happening at the same time that the behavior occurs?”

Identify consequent conditions:Determine what events occur immediately after the behavior. Ask, “What happensafter the problem behavior occurs?” “What seems to stop this behavior?”

Tentative-definition-of-goal question:Determine what level or extent of the behavior, if any, is acceptable. For example,ask, “How often could the student leave his seat without causing problems?” “Is thebehavior acceptable under any other circumstances?”

Approach to teaching or using existing procedures:Explore procedures or rules. Ask, “Is there a rule associated with this behavior?”“Is there a routine associated with this behavior?” “Is there a replacement behaviorto substitute for this maladaptive behavior?”

Identify student strengths (examples:Peer social skills Leader Verbal SkillsMotivated to change Cooperative Academic skillsEngages adults Positive attitude Athletic skillsSense of humor Future plans Fine arts skillsSeeks information Interest areas Hobbies

Identify reinforcers for student:Ask, “What does the student like to do?”

Identify strategies already tried (indicate duration/outcome:Private talk with student Parent calls/conferences Assignment sheetsProximity control Verbal reminders Alternative testingStudy carrel Charting & graphing progress Assistive technologyContracts Planned ignoring Ancillary staff contactPlanned time out Positive reinforcement MedicationChanged seating Reduced day/schedule adjusted RetentionAdjusted assignments Progress reports Other: Tutoring Mentorship Other:


Set timer for 2 minutes.Step 2: Describe desired state.• In a sentence, describe desired state (goal) or identify replacement behavior.

Set timer for 4 minutes.Step 3: Identify influencing variables.• Review FAB model, Process Checklist, ABC sheets, or Scatter Plot. Consider

any pattern of antecedent and consequent conditions: person, place, time, andevents.

Set timer for 4 minutes.Step 4: Generate one or more hypotheses from analysis of available data.• List possible hypotheses to explain function(s) of problem behavior (see FAB

model for suggestions).

Set timer for 3 minutes.Step 5: Identify strategies to promote positive change.• Brainstorm ideas; consider all contributions.


Set timer for 3 minutes.Step 6: Select Strategies to Implement.

Set timer for 4 minutes.Step 7: Attend to final details.• Assess: How do you know if the plan is working? What data do you need?

Plan Summary: Identify how parents and other people or resources can sup-port the plan. Identify responsibilities, actions, and deadlines and schedulefollow-up meeting. Include who will obtain student input on the plan if thestudent did not participate in this meeting.

Who? Does What? By When?

Schedule follow up meeting to review and revise:

When?

Where?

Who should attend?


Functional Assessment of Behavior/Behavior Intervention PlanFrances Mueller, Oakland Schools and

Beverly Pears, Royal Oak Public Schools

Student Date

Birth date School Classroom/Grade

Parents invited to participate by Date(Name)

Individuals Participating

Name/Title or Relationship to Student Name/Title or Relationship to Student

1. Identify the target behavior(s).

? “What does the student do?”

1.

2.

2. Prioritize target behavior(s).

Behavior 1.1. Does the behavior threaten the life of the student or others? Yes No2. Does the behavior threaten the physical well being of the student or others?Yes No3. Does the behavior interfere with the educational progress of the student? Yes No4. Does the behavior interfere with the educational progress of others? Yes No5. Does the behavior result in materials destruction or damage? Yes No6. Will the behavior become more serious without intervention now? Yes No7. Does the behavior interfere with acceptance by peers or adults? Yes No

Behavior 21. Does the behavior threaten the life of the student or others? Yes No2. Does the behavior threaten the physical well being of the student or others?Yes No3. Does the behavior interfere with the educational progress of the student? Yes No4. Does the behavior interfere with the educational progress of others? Yes No5. Does the behavior result in materials destruction or damage? Yes No6. Will the behavior become more serious without intervention now? Yes No7. Does the behavior interfere with acceptance by peers or adults? Yes No

3. Describe target behavior(s).

Behavior 1 Behavior 2

a. Frequency: How often does it occur? a. Frequency: How often does it occur?

b. Rate: How fast? b. Rate: How fast? c. Duration: How long does it last? c. Duration: How long does it last? d. Intensity: How much? d. Intensity: How much? e. Is this unique or typical behavior? e. Is this unique or typical behavior?

Complete the prioritization of behaviors.

List the behavior(s) in order of priority.

1.

2.

Circle the number(s) of the behavior(s) selected for intervention now.

4.Where does the target behavior(s) occur? ? “Where does the student engage in target behavior(s)?” and “Where does the student not engage in target behavior(s)?”

Behavior Location(s) present Location(s) not present

1.

2.

Where does the target behavior occur most frequently?

Functional Assessment of Behavior/Behavior Intervention Plan 2

5. When do(es) the target behavior(s) occur? ? “When in the day does the student do this behavior? When does it not occur?”

Behavior Time does occur Time does not occur

1.

2.

When does the target behavior occur most frequently?

6. What is the student’s disability?

How may this disability affect target behavior(s)?

7. Identify antecedent conditions. ? “What happens right before the student does the target behavior(s)?”

Behavior Antecedents/Triggers

1.

2.

8. Identify simultaneous conditions. ? “What else is happening at the same time as when the behavior occurs?”

Behavior Simultaneous or Same-time Conditions

1.

2.

9. Identify consequent conditions.? “What happens after the target behavior occurs?”

Behavior Consequent or Following Events

1.

2.


10. Determine if any level or extent of target behavior is acceptable.? “How often could the student do the behavior without causing problems?” “Is the behavior acceptable under any circumstances?”

Behavior Acceptable Level/Circumstance(s)

1.

2.

11. Use rules, routines, and replacement behaviors. ? “Is there a rule associated to this behavior?” “Is there a routine that is associated with this behavior?” “Is there a replacement behavior that can be a substitute for this maladaptive behavior?” Is there a replacement behavior that can be taught?”

Behavior Rules and/or routines Replacement behaviors

1.

2.

12. Identify student strengths. Refer to suggestions on page 9.

13. Identify reinforcers for student. Refer to suggestions on page 9. ? “What does the student like to do?”

14. Identify strategies/intervention already tried. Indicate when, how long, and outcome. Refer to suggestions on page 9.

Tried When Outcome


15. Describe expected outcome(s) or goal(s) in measurable terms.

Behavior Outcome(s)/Goal(s)

1.

2.

16. Consider behavioral patterns identified in steps 4-9. Behavior Patterns of Antecedent Simultaneous Consequent Conditions

1.

2.

17. Generate one or more hypotheses from behavioral patterns identified in step 16.

Behavior Hypothesis

1.

2.

18a. Non judgmental brainstorming: Strategies/interventions to promote expected goal or teach replacement behavior(s). Refer to Judy Wood SAALE materials for ideas. Refer to list of student strengths and student preferred reinforcers.

Behavior Strategy(ies)/Intervention(s)

1.

2.


18b. Select strategies/interventions to implement from the brainstorming list.

Behavior Strategies/Interventions

1.

2.

19. Assess change in target behavior(s).

Behavior Data

1.

2.

20. Determine action plan for implementation. Who? Does What? By When?

21. The plan is to be implemented on (Date)

22. Identify Plan Coordinator: [responsible for scheduling future review meeting (s)]


23. This plan for will be reviewed on:

Date

Time

Approximate length of meeting?

Where?

Who needs to be there? (Check)

parent student

psychologist social worker

counselor principal or designee

speech and language pathologist occupational therapist

physical therapist general education teacher (s)

special education teacher (s) paraprofessional support staff

special education administrator other

other other

24. I understand this plan and request its implementation as described in this

document. I understand that this document may be revised through school staff

and parent agreement.

Signed Date

Parent/Guardian/Student if 18 or older

This plan was reviewed with the student on

(Date )

by .

(Person’s name)


Addendum of Revisions

Date plan was first written

First date of plan implementation

Date of revision(s)

Participants in writing revision

Describe revision of plan

Date revised plan to be implemented

Parent aware of changes to the plan and agreed to implementation of revised plan.

Parent unable to attend meeting but contact for plan approval was made.

Staff Date

By phone

Other (specify)

Copy of revisions sent home


Suggestions for Student StrengthsPeer social skills Leader Verbal Skills Motivated to change

Cooperative Academic Skills Engages adults Positive attitude

Athletic skills Sense of humor Future plans Fine arts skills

Seeks information Interest areas Hobbies Like routines

Like rules Likes breaks Likes to help Likes quiet environment

Suggestions for Student ReinforcersBe first in line Access to snack machines Attend school dances

Attend school assemblies Care for class pet Decorate classroom

Extra portion at lunch Extra P.E., recess, or break Free use of equipment

Display work publicly Help adult in school Pass out papers

Run errands Sit at teacher’s desk Sit by a friend

Tutor students Visit library Water class plants

Write on chalkboard Tell class a joke Listen to music

Smiles/praise Free homework night Phone call to parents

Parent visit Positive comments on work Field trip

Extra time for recess Water plants Free time in class

Suggestions for Strategies/Interventions

Private talk with student Proximity control Verbal reminders

Alternative testing Study Carrel Charting and graphing progress

Assistive technology Contracts Planned ignoring

Ancillary staff contact Planned time out Positive reinforcement

Medication adjusted Change seating Adjust/modify schedule

Adjusted assignments Progress reports Tutoring

Mentorship Assignment sheets Parent calls/conferences

Alternate passing time Visual schedule Other ( works at home):

Other (at school): Social skills training Change instructional pace

Change curriculum content Change instructor Change instructional approach

Define rules: individualize Provide choices Develop student work system

Use visual organizers Provide visual cues Check for understanding

Build routines Simplify directions Build consistent schedule

Planned breaks Cooperative learning Consult previous teacher

Signal Interference Academic assistance Self-monitor/self-control training

Model desired behaviors Direct instruction of skill deficit


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