Mesa Public Schools

Chandler Unified School District Positive Behavior Intervention Plan

Student Name: Home Phone: Date: Date of Birth: Home Address: Student No:

Age Gender Grade Home School Attending School

Ethnicity Primary Language/Date Home Language/Date Determined Determined

Parent/Guardian Name Home Phone Parent/Guardian Name Home Phone

Address Work Phone Address Work Phone

Emergency Phone Emergency Phone

Team Members An individual behavior plan is a clearly stated working document which incorporates information from a functional behavior assessment and describes the goals and methods intended to modify a students negative behavior. A separate plan may be required for each targeted behavior. A successful behavior plan eliminates the negative behavior and allows the student to fulfill the function of the negative behavior through the development of new, positive behaviors. (Note: Behavioral consequences should protect the health and self-esteem of the student and be consistent with local guidelines regarding the use of aversives.)

Team members who participated in developing the plan Positions Names

Student Parent/Guardian Case Manager Psychologist General Education Teacher Other: Other:

I. Target Behavior II. Replacement Behavior (What the student should do in place of the problem behhavior to get his/her need(s) [gain, avoid, protest] in an acceptable way?)

III. Identified Positive Reinforcers (Based upon administration of a positive reinforcer survey, parent input, student interview, etc.)

IV. Environmental Strategies/Supports to be Implemented (considerations but not exclusive nor exhaustive)

Strategy/Support Frequency Person Responsible

V. Instructional Strategies to be Implemented (considerations but not exclusive nor exhaustive)

Strategy Frequency Person Responsible

VI. Implementation Plan

When Student Does… Frequency Student will Earn… Person Responsible

VII. Staff Response to Undesirable Behavior(s) (Outline the team’s plan/steps to be taken [in increasing order of consequence, less to most restrictive] if the student does not show desired progress on the implementation plan.)

VIII. Materials Needed to Implement Plan, If Applicable

Materials Needed Person Responsible for Obtaining/Creating

IX. Monitoring Person to manage BIP and collect data Data will be collected: and reviewed: Date of BIP Inititation:

IEP amended and PWN completed and attached to IEP Date:

X. Review of BIP Effectiveness (Behavior plan should be reviewed 4-6 weeks after date of initiation. Discuss student’s progress/performance since the plan was initiated and any modifications proposed, if applicable. If BIP is being terminated, please indicate date of termination)

Date of 1st BIP Review Meeting:

Team Members [and position] Attending: Discussion of Student Progress and Recommendations:

Projected Date of Next Review, if applicable:

Date of 2nd BIP Review Meeting:

Date of 3rd BIP Review Meeting: