Functional Behavioral Assessment and Behavioral Intervention Plan

1. Functional Behavioral Assessment and Behavioral Intervention Plan RtI Tier 3 - Comprehensive Page ___ of ___ Student: Student #: D.O.B: School: Exceptionalities: Grade: Date of Report: Records Review: Team Members (those involved in assessment/interventions) (check those which apply) Name Academic/Cum/Audit Disciplinary Records Anecdotal Records Evaluations/Assessments Previous Interventions Progress Notes to Family Child Study Team Notes Samples of Student’s Work Other: Title Records reviewed by: Relevant Information: (obtained from records review, interviews, and/or direct observations) Brevard Public Schools Rational for Assessment and Interventions Student is engaging in behavior that places the student or others at risk of harm and/or results in substantial property damage. Behavioral concerns are resulting in exclusion from participation in activities or settings with peers. Educational team is considering a more restrictive placement due to behavior concerns. Current intervention involves excessively intrusive interventions (e.g. restraint, isolation.) Student’s behavioral difficulties persist despite consistently implemented behavior management strategies based on a less comprehensive or systematic assessment. Other: Student Strengths/Assets: Motivators/Reinforcers: Review of FBA/BIP: (signature and date) Revised 07-07-10 FBA/BIP - Comprehensive

2. Student: Student #: Date: School: Page ___ of ___ Target behavior #1: Define target behavior:(What does it look like?) How often does it occur? (i.e. 2 x’s a day, 5 x’s per week) How long does it last? (i.e. 3-5 minutes, 30 seconds) Severity of behavior: Mild: Little risk to property or health/disruption to class 5 minutes or less per hour Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour Situations when the behavior is least likely to occur: (i.e. times of day, activity, subject, specific people present) Situations when the behavior is most likely to occur: (i.e. times of day, activity, subject, specific people present) Functional Behavioral Assessment Brevard Public Schools Antecedents: What happens immediately before the target behavior occurs? Consequences: What happens immediately after the target behavior occurs? (Specify/Describe) Function/purpose of behavior: Preferred items/materials Preferred activities Preferred people/social situations Student receives access to: Student avoids/escapes: Student receives attention (+/-) from peers Student receives attention (+/-) from adults Behavior is self stimulating/entertaining and/or feels good Behavior relieves discomfort or pain (Specify/Describe) Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations Revised 07-07-10 FBA/BIP - Comprehensive

3. Student: Student #: Date: School: Page ___ of ___ Target behavior #2: Define target behavior:(What does it look like?) How often does it occur? (i.e. 2 x’s a day, 5 x’s per week) How long does it last? (i.e. 3-5 minutes, 30 seconds) Severity of behavior: Mild: Little risk to property or health/disruption to class 5 minutes or less per hour Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour Situations when the behavior is least likely to occur: (i.e. times of day, activity, subject, specific people present) Situations when the behavior is most likely to occur: (i.e. times of day, activity, subject, specific people present) Functional Behavioral Assessment Brevard Public Schools Antecedents: What happens immediately before the target behavior occurs? Consequences: What happens immediately after the target behavior occurs? (Specify/Describe) Function/purpose of behavior: Preferred items/materials Preferred activities Preferred people/social situations Student receives access to: Student avoids/escapes: Student receives attention (+/-) from peers Student receives attention (+/-) from adults Behavior is self stimulating/entertaining and/or feels good Behavior relieves discomfort or pain (Specify/Describe) Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations Revised 07-07-10 FBA/BIP – Comprehensive

4. Student: Student #: Date: School: Page ___ of ___ Target behavior #3: Define target behavior:(What does it look like?) How long does it last? (i.e. 3-5 minutes, 30 seconds) How often does it occur? (i.e. 2 x’s a day, 5 x’s per week) Severity of behavior: Mild: Little risk to property or health/disruption to class 5 minutes or less per hour Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour Situations when the behavior is least likely to occur: (i.e. times of day, activity, subject, specific people present) Situations when the behavior is most likely to occur: (i.e. times of day, activity, subject, specific people present) Functional Behavioral Assessment Brevard Public Schools Antecedents: What happens immediately before the target behavior occurs? Consequences: What happens immediately after the target behavior occurs? (Specify/Describe) Function/purpose of behavior: Preferred items/materials Preferred activities Preferred people/social situations Student receives access to: Student avoids/escapes: Student receives attention (+/-) from peers Student receives attention (+/-) from adults Behavior is self stimulating/entertaining and/or feels good Behavior relieves discomfort or pain (Specify/Describe) Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations Revised 07-07-10 FBA/BIP - Comprehensive

5. Student: Student #: Date: School: Page ___ of ___ Target behavior #4: Define target behavior:(What does it look like?) How often does it occur? (i.e. 2 x’s a day, 5 x’s per week) How long does it last? (i.e. 3-5 minutes, 30 seconds) Severity of behavior: Mild: Little risk to property or health/disruption to class 5 minutes or less per hour Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour Situations when the behavior is least likely to occur: (i.e. times of day, activity, subject, specific people present) Situations when the behavior is most likely to occur: (i.e. times of day, activity, subject, specific people present) Functional Behavioral Assessment Brevard Public Schools Antecedents: What happens immediately before the target behavior occurs? Consequences: What happens immediately after the target behavior occurs? (Specify/Describe) Function/purpose of behavior: Preferred items/materials Preferred activities Preferred people/social situations Student receives access to: Student avoids/escapes: Student receives attention (+/-) from peers Student receives attention (+/-) from adults Behavior is self stimulating/entertaining and/or feels good Behavior relieves discomfort or pain (Specify/Describe) Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations Revised 07-07-10 FBA/BIP - Comprehensive

6. Student: Student #: Date: School: Page ___ of ___ Preventative Interventions: What environmental adjustments will be used to make the student’s problem behavior no longer necessary? • Modifying physical settings or routines • Modifying staff approaches • Clarifying expectations • New processes of monitoring/reporting progress Behavioral Intervention Plan Brevard Public Schools Interventions for Replacement Behaviors: What behaviors will you teach so that the student no longer needs to engage in the target behavior(s) to get this need met? Revised 07-07-10 FBA/BIP - Comprehensive

7. Student: Student #: Date: School: Page ___ of ___ Functional Interventions: How will the environment change when the student engages in the desired replacement behavior(s)? How will the environment change when the student engages in the problem behavior? • Student will receive access to preferred items, activities, social situations • Positive attention from others • Free time • Tokens, stickers, special recognition • Student is ignored • Student not permitted access to preferred items, activities, social situations Behavioral Intervention Plan Brevard Public Schools Crisis Management Plan: District approved Crisis Prevention and Intervention (CPI) techniques will be used as warranted to prevent crisis situations from arising, facilitate de-escalation of potentially dangerous behavior, and to ensure safety of self and others. Monitoring (Who and how will data be collected to assess Response to Intervention?): Evaluation (Who and when will the Behavioral Intervention Plan be reviewed and/or revised? Teacher will maintain daily data collection on form attached. Child Study/IEP Team will review data and modify interventions in this plan: as needed to ensure progress. (when) Revised 07-07-10 FBA/BIP - Comprehensive

8. Page ___ of ___ Data Collection RE: Target Behavior # ____ Data Collection RE: Replacement Behavior Definition of Replacement Behavior: Brevard Public Schools

9. Page ___ of ___ Data Collection RE: Target Behavior # ____ Data Collection RE: Replacement Behavior Definition of Replacement Behavior: Brevard Public Schools