Confidential and Privileged Student Information for Professional Use Only

PASCO COUNTY SCHOOLS CONFIDENTIAL AND PRIVILEGED STUDENT INFORMATION FOR PROFESSIONAL USE ONLY Brief Functional Behavior Assessment – Behavior Intervention Plan Demographics Student name: ID#: Date: School: Grade: DOB:

Parent / guardian: Gender: Basic Ed: 504: Male Female Yes No Y No e s Exceptionality(ies): ELL: PMP area: Yes No Primary: Other: Yes No If Yes, what area(s)? Reading Writing Science Medical diagnosis, if applicable: Primary: Previous retention? Additional: Yes No Medications, if applicable/known: Retention Grade(s):

Team liaison / case manager: Referral source: Previous FBA date(s):

Other team members (name, role):

What sources were used to gather information Student Interview Parent Interview Teacher Interview Rating Scales Direct Observation Record Review Other

Was the Behavior Intervention Plan (BIP) developed and implemented within 30 days of the Functional Assessment? Yes No Written date: Implementation date:

Does the student’s problem behavior require implementation of a Crisis Plan? Yes No

If the team indicates a Crisis Plan is needed, develop a plan on the Crisis Plan form.

Functional Assessment Step one: Problem Identification (Define the Problem Behavior) Considerations:  If the team has more than one problem behavior, complete the Comprehensive FBA/BIP process.  If the team indicates a need for a Crisis Plan, develop a plan on the Crisis Plan form and begin the Comprehensive FBA/BIP process. What is the primary behavior of concern? Ex. Johnny is ripping up paper and throwing it on the floor.

Examples: What is the student doing/saying? (ie., ripping up paper and throwing it to the floor, leaving desk and walking more than 3 feet away, making vocalizations during instruction) Step two: Problem Analysis (Determine the Function) Please list the student’s schedule and how likely the behavior is to occur during that activity/subject: Scale: 1 = Occurs 1-2x per month, 2 = Occurs 1x per week, 3 = Occurs 2-4x per week, 4 = Occurs 1-5x per day, 5 = Occurs 6-10x per day, 6 = >10 times per day Activity/subject/course Likelihood of problem Types of activities Teacher Name Independent work Whole/large group Low High Small group Transition 1 DSBPC - Rev 7/14/14 1 2 3 4 5 6 Non-academic task Activity with peer Independent work Whole/large group Low High Small group Transition 1 2 3 4 5 6 Non-academic task Activity with peer Independent work Whole/large group Low High Small group Transition 1 2 3 4 5 6 Non-academic task Activity with peer Independent work Whole/large group Low High Small group Transition 1 2 3 4 5 6 Non-academic task Activity with peer Independent work Whole/large group Low High Small group Transition 1 2 3 4 5 6 Non-academic task Activity with peer Independent work Whole/large group Low High Small group Transition 1 2 3 4 5 6 Non-academic task Activity with peer Independent work Whole/large group Low High Small group Transition 1 2 3 4 5 6 Non-academic task Activity with peer

Setting Events 1. Are there conditions in the physical environment that are associated with a high probability of problem behavior? For example, too warm or too cold, too crowded, too much noise, too chaotic, weather conditions, etc.

2. Are there circumstances unrelated to the school setting that occur on some days and not other days that may make problem behavior more likely? Aller Chan Hung Parties or social event gie ge er s in ro uti ne Bus Drug/ Horm Physical condition co alc on nfl oh es ict ol or ab me us nst e rua tio n Chan Fatig Illnes Parent not home ge ue s in die t Chan Hom No Sleep deprivation ge e me in co dic me nfl ati dic ict on ati 2 on Other: If setting events are identified, explain the relationship of the setting events to the problem behavior.

Antecedents What happens immediately before the problem behavior occurs? Being told work is wrong Removal of preferred item Student is not receiving attention Denied Access to item/activity Reprimand or correction Teacher is attending to other students “Down time” (no task specified) Request to start task Told “no” or “wait” End of preferred activity Schedule change Transition Novel task Setting change Unstructured activity Peer behaviors: Start of non-preferred activity Other /Additional observation:

Consequences What do other (adult or peers) immediately say or do after the student engages in the problem behavior? Activity changed Natural consequences (Specify) Sent home Activity terminated Peer reaction (Specify) Sent to behavior specialist/counselor Assistance given Physical prompt Sent to office Break Physical restraint Sent to time-out Calming/soothing Reminded of rules Teacher positive attention Change setting Removal of reinforcers Teacher negative attention Delay in activity Seclusion Verbal redirect Ignore Give access to item/activity Verbal reprimand Other /Additional observation:

Function Based on the Problem Analysis, why is the problem behavior occurring? (What is the payoff? What rewards /maintains the behavior?) Consideration: If the team has identified more than one possible function for the problem behavior, complete the Comprehensive FBA/BIP process. To obtain or gain something To escape or avoid something Peer attention Teacher attention Peer attention Teacher attention Item Activity Item Activity Sensory stimulation (under sensitivity, ie., jumping, flapping) Sensory stimulation (over sensitivity, ie., bright lights, noise) Hypothesis 1. Antecedent: Summarize items marked in Antecedent section 1-7. 2. Problem Behavior: Copy and paste from Problem Behavior section 1. 3. Consequence: Summarize items marked in Consequences section 8. 4. Replacement Behavior: The replacement behavior developed must allow the student to achieve the same function as the problem behavior (e.g. escape, gain attention, etc.) 1. Antecedent 2. Problem behavior 3. Consequence 4. Replacement Behavior When… The student will… In order to… Instead, the student will …

Ex: When Johnny is presented with a Ex: Johnny will rip up the materials Ex: In order to escape the task. Ex. Johnny will verbally express his task… provided. want or need for a break from the task

Behavior Intervention Plan Demographics 3 DSBPC - Rev 7/14/14 Student name: ID#: School: Grade: DOB:

Plan date: Implementation date: Revision date: Discontinued date:

Target Behaviors Directions: Develop measureable goals for the replacement behavior and problem behavior. Replacement behavior goal:

Ex: Johnny will ask for break in order to escape a non-preferred task 80% of the time. Problem behavior goal:

Ex: Johnny will reduce ripping up paper and throwing it on the floor to less then 20% of the time. Step three: Intervention Development and Implementation (Determine by the Function) Interventions Antecedent interventions What will you do to prevent the behavior from occurring? Increased home/school Modify amount of work Change who is around communication Modify presentation of work Provide extra help Other: Provide choices Increase supervision Other: Teaching Interventions What desired skills will you teach to replace the problem behavior? Asking for help Asking for alone time Problem solving Asking for a break Asking for attention Other: Managing feelings Asking for an activity Other: Consequence / Reinforcement interventions How will you maximize the reinforcement of replacement behavior by providing the same outcome (e.g. function) as the problem behavior? Provide attention Provide down time Other: Provide breaks Allow student to pick class activity Other: Provide work choice Preferred activity or object Other:

How will you minimize the reinforcement of problem behavior so that the student will no longer obtain the same outcome? Provide consistent verbal praise for Acknowledge when student is doing the right thing new skill Other: No eye contact or response/ ignore Prompt appropriate behavior Other: Offer assistance with academics Reward other students who are working/on task Other: Intervention Plan What will be done? Who is When will it Where will How will support be provided for the responsible? occur? it occur? intervention? Teacher Guidance/Behavior Specialist will conference with Example – When Johnny rips up paper and throws teacher once a week to ensure understanding and it on the floor, the teacher will prompt him to ask Daily Classroom Instructional fidelity of intervention for a break. assistant

4 Fidelity Plan Develop a plan to assess the fidelity of the BIP implementation. Set a date within four weeks for the team to meet and review the fidelity of implementation and data collected. What will be done? Who is When will it Where will it Date for follow up responsible? occur? occur? meeting.

Data collection Directions: Record the date below each day’s label. Circle a rating for desired behaviors and problem behaviors. Set anchor points for the behaviors based on the student’s current levels of replacement behaviors and problem behaviors. For example Replacement behavior: Asking for a break 5 = more than 10 occurrences, 4 = 7-9 occurrences, 3 = 4-6 occurrences, 2 = 1-3 occurrences, 1 – No occurrences Problem behavior: Hitting teacher and staff 5 = more than 20 occurrences, 4 = 15-19 occurrences, 3 = 10-14 occurrences, 2 = 5-9 occurrences, 1 – Less than 5 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Insert date Insert date Insert date Insert date Insert date Insert date Insert date Insert date Insert date Insert date Replacement behavior - Define anchor:

5 5 5 5 5 5 5 5 5 5

4 4 4 4 4 4 4 4 4 4

3 3 3 3 3 3 3 3 3 3

2 2 2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 1 1 1

Problem behavior - Define anchor:

5 5 5 5 5 5 5 5 5 5

4 4 4 4 4 4 4 4 4 4

3 3 3 3 3 3 3 3 3 3

2 2 2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 1 1 1

Step four: Response to Intervention (Review the Fidelity and Student Data) Response Date: Rate the fidelity of implementation. As Planned Inconsistent Not as planned If fidelity is inconsistent or not as planned (above), develop plan to increase fidelity: Retrain/coach teacher/implementer on the plan Modify the interventions so that they are feasible for implementation (Revise Intervention and Fidelity Plan and collect additional data) 5 DSBPC - Rev 7/14/14 Develop different interventions that match the hypothesis and are more feasible for the teacher to implement (Revise Intervention and Fidelity Plan and collect additional data)

Date of follow-up meeting to review additional fidelity data (Do not proceed unless fidelity is As Planned)

Replacement Behavior? No change Increase Decrease Inconsistent Problem Behavior? No change Increase Decrease Inconsistent Decision Maintain intervention plan – Explain: Modify plan from choices below: Conduct a Comprehensive FBA/BIP Establish new goal/increase criterion Expand the interventions (additional people, settings, routines) Fade intervention components (Revise Intervention and Fidelity Plan, collect additional data and complete Step four: Response to Intervention) Discontinue Tier III supports and continue or develop Tier II supports – Explain:

Cc: Parent Cumulative folder Teacher