Mecklenburg County Public Schools s1

MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:FUNCTIONAL BEHAVIOR ASSESSMENT (FBA) REFERRALDATE OF INITIAL REFERRAL: STUDENT’S TEACHER(S): DATE PARENT WAS REFERRING SOURCE: NOTIFIED : PARENT / GUARDIAN: HOME TELEPHONE #: 911 ADDRESS: WORK TELEPHONE #: MAILING ADDRESS IF DIFFERENT: CELL PHONE #: IS PARENT/GUARDIAN THE NATURAL PARENT? YES NO IF NOT, STATE RELATIONSHIP AND ATTACH LEGAL DOCUMENTS TO SUPPORT GUARDIANSHIP: IS THE STUDENT AND PARENT A RESIDENT OF MECKLENBURG COUNTY? YES NOTHE FOLLOWING MUST BE ATTACHED CURRENT CLASSROOM GRADES TEACHER INFORMATION FORM TEACHER DATA FORM(S) INVITATION TO FBA MEETINGSEND A COPY TO DIAGNOSTIC CENTER IF THE STUDENT RECEIVES SPECIAL EDUCATION SERVICESCONFIDENTIAL Page 1 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:NOTIFICATION OF FUNCTIONAL BEHAVIOR ASSESSMENT MEETINGDate: Initial MeetingFollow-Up MeetingStudent: Dear Parent/Guardian:Your child has been referred for a Functional Behavior Assessment (FBA) by . Members of the committee will discuss behavior issues related to your child. Your input is important and you are encouraged to participate with this discussion. The meeting has been scheduled for:DATE: TIME: LOCATION: If this date and time are inconvenient for you, please call and ask for or the principal.Invited:Parent/Guardian School PsychologistSchool Administrator Special Education TeacherClassroom Teacher Specialist Child/Student (as appropriate) The parent/adult student or school division may invite individuals who have knowledge or special expertise regarding the student to participate as a member of the Functional Behavior Assessment (FBA) team. The determination of the knowledge or special expertise shall be made by the person extending the invitation. If you, the parent or adult student, are bringing other individuals to the meeting, please call to ensure that the meeting space will accommodate all team members.TEACHER INFORMATION FORM ONE FORM FOR EACH PROBLEM BEHAVIOR CONFIDENTIAL Page 2 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:STUDENT: DATE: TEACHER: 1. Describe the targeted problem behavior: 2. Did the behavior result in an injury? No Yes If yes, describe: 3. Where did the behavior occur? School Bus (Attach Teacher Data Form)Is this a reoccurring behavior? If yes, how often has it happened? How long did it last? How intense was the behavior? 4. What was happening when the behavior occurred? Who was present? (staff and/or students)? What subject/activity was occurring at the time of the event(s)? What type of instruction (if any) was the student receiving just prior to the event(s)?Seatwork Small group instructionLarge group lecture Small group projectLarge group discussion Test/quizPresentation Other: Did another student or staff member do or say something that might have set off the event/behavior? Yes NoIf Yes, describe: 5. How did staff and students react? How did you deal with the student’s behavior?Ignored Name on board ReprimandLoss of Privilege Calm, Neutral Discussion Sent to OfficeInterrupt, redirect Sent to another classroom ReferralCalled parent Time-out Sent homeOther: 6. Describe types of interventions utilized and effect on student: CONFIDENTIAL Page 3 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:TEACHER DATA FORMTargeted Problem Behavior: DATE TIME SETTING WHAT BEHAVIOR CONSEQUENCES (CLASSROOM, HAPPENED (REACTION FROM STAFF/STUDENTS, HALL, ETC. AND BEFORE WHO WAS AND HOW WAS THE BEHAVIOR PRESENT) BEHAVIOR DEALT OCCURED WITH)TEACHER: STUDENT: CONFIDENTIAL Page 4 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:ONE DATA FORM FOR EACH PROBLEM BEHAVIOR PARENT INTERVIEWSTUDENT: PARENT: DATE: PERSON COMPLETING THE FORM: 1. Medical History:Recent Illness: Mental Health Diagnosis: Taking Medication: Recent Accidents: Other: 2. Family Issues:Recent Illnesses: Conflicts: Death in the Family: Moves: Changes (loss of income, new member in the family, etc. Other: 3. Any Behavior Problems at Home and/or Community: 4. Parent Expectations (goals, behavior, expectations, etc.): 5. Rewards and Consequences at home: 6. Other: CONFIDENTIAL Page 5 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:STUDENT INTERVIEWSTUDENT: DATE: PERSON COMPLETING THE FORM: 1. Tell me about things that seem to be going well/not going well at school?Going well? Not Going Well? 2. Tell me about where you seem to have the most/least problems at school:Most problems? Least problems? 3. Tell me about the problems in school? What does the teacher/students say or do?4. What were you thinking right before the problem happened?5. Why do you think you keep getting or have gotten into trouble?6. Tell me about the things you like/dislike at school, home, and other places?Likes? Dislikes? 7. Goals? CONFIDENTIAL Page 6 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:FUNCTIONAL BEHAVIORAL ASSESSMENTSTUDENT: DATE: Data Sources: Teacher Data Form Teacher Information Form Student Interview Parent Interview OtherIDENTIFY TARGETED PROBLEM BEHAVIOR: SETTING(S) IN WHICH BEHAVIOR OCCURS: Specific days or times of day: Settings (class, hallway, home, etc.): Particular subject areas: Type or Length of task (writing, independent work, unstructured time, etc.): Manner of presenting instruction (group, lecture, etc): Particular Persons: Environmental Characteristics: Transitions (changing classes, etc.): Other: FREQUENCY/DURATION/PATTERN (HOW OFTEN IS THE TARGETED PROBLEM BEHAVIOR OCCURING):CONSEQUENCES OF BEHAVIOR (REACTION FROM STAFF AND STUDENTS AND HOW WAS THE BEHAVIOR DEALT WITH):DESCRIBE PREVIOUS INTERVENTIONS AND IF THEY WERE SUCCESSFUL:EDUCATIONAL IMPACT: IS THE STUDENT AWARE OF EXPECTED BEHAVIOR AND UNDERSTAND CONSEQUENCES OF HIS/HER BEHAVIOR: YES NOATTENDANCE OVER THE PAST YEAR: CONFIDENTIAL Page 7 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:FUNCTION OF BEHAVIOR (Specify hypothesized function for each area checked below):Family Issues (Identify family issues that play a part in organizing and directing problem behavior):Health or Emotional State (Identify emotional factors such as anxiety, depression, poor self-concept, illnesses, etc):Cognitive Distortion (Student’s perception, irrational thoughts, etc.):Curriculum/Instruction (Identify how instruction, curriculum, or educational environment play a part in organizing and directing problem behavior): Communicate needs (Identify what the student is trying to say through the targeted problem behavior):Reinforcement (Identify payoffs): Power or Control (Identify what student is trying to control): Revenge (Identify why the student has a need to get revenge): Acceptance (Identify why they are seeking acceptance and from whom): Escape and/or Avoidance (Identify what the student is trying to avoid or escape from): Attention (identify attention seeking behavior): Self-Stimulation/ Self-Regulation: Other: REPLACEMENT BEHAVIOR IDENTIFICATION (The goal of a FBA is to replace inappropriate behavior with appropriate (desired) behavior) (Identify desired behavior):HYPOTHESIS STATEMENT (An explanation that represents the best “guess” regarding the reasons for the targeted problem behavior)RECOMMENDATIONS FOR INTERVENTION (MINIMUM OF 3 WEEKS IN IMPLEMENTING INTERVENTIONS): Modification of school day/schedule Changes in classes/subject area Changes in instructor Modification of curriculum/academic programs Modifications of learning activities/tasks Changes in manner of presenting instruction/feedback Modification of physical environment Modification of expectationsCONFIDENTIAL Page 8 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:Home/Family issues to be addressed Address emotional/anger issues Address peer issues Address social skill issues Review IEP goals and objectives (if applicable) Develop Behavior Intervention Plan Other: MEMBERS PRESENT: Participant Relationship to StudentCONFIDENTIAL Page 9 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:NOTIFICATION OF BEHAVIOR INTERVENTION PLAN MEETINGDate: Initial MeetingFollow-Up MeetingStudent: Dear Parent/Guardian:Your child has been referred for a Behavior Intervention Plan (BIP) by . Members of the committee will discuss behavior issues related to your child. Your input is important and you are encouraged to participate with this discussion.DATE: TIME: LOCATION: If this date and time are inconvenient for you, please call and ask for or the principal.Invited:Parent/Guardian School PsychologistSchool Administrator Special Education TeacherClassroom Teacher Specialist Child/Student (as appropriate) The parent/adult student or school division may invite individuals who have knowledge or special expertise regarding the student to participate as a member of the Behavior Intervention Plan (BIP) team. The determination of the knowledge or special expertise shall be made by the person extending the invitation. If you, the parent or adult student, are bringing other individuals to the meeting, please call to ensure that the meeting space will accommodate all team members.CONFIDENTIAL Page 10 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:BEHAVIORAL INTERVENTION PLANSTUDENT: DATE: Special Education: YES NOIDENTIFY TARGETED PROBLEM BEHAVIOR: HYPOTHESIS FUNCTION OF THE PROBLEM BEHAVIOR: DESIRED REPLACEMENT BEHAVIOR: ACCOMMODATIONS TO ASSIST THE STUDENT IN DISPLAYING THE REPLACEMENT BEHAVIOR:Clear, Concise Directions Review Rules and Expectations Frequent Reminders/Prompts Supervise Free Time Frequent Breaks/Vary Activities Avoid Strong Criticism Teacher/ Staff Proximity Predictable, Routine Schedule Modify Assignments Specified Study Area Preferential Seating Avoid Power Struggles Define Limits Behavior Contract Provide Cooling Off Period Provide highly-Structured Setting Communicate Regularly with Parents Other: Other: Other: Other: Other: METHODS OF MEASURING PROGRESS:Direct Observation Self-monitoring Daily Behavior Sheet Number of Discipline Referrals Weekly Behavior Sheet Other: Other: Other: Other: Other: Other: Other: POSITIVE CONSEQUENCES FOR DISPLAYING THE REPLACEMENT BEHAVIOR:Verbal Praise Positive Phone Call/Note Home Computer Time Free Time Immediate Feedback Tangible Rewards Earned Privileges Predictable, Routine Schedule Other: Other: Other: Other: CONFIDENTIAL Page 11 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:BEHAVIORAL INTERVENTION PLAN, ContinuedPERSONS RESPONSIBLE FOR IMPLEMENTING THE PLAN:General Education Teacher Special Education Teacher School Administrator Parent Paraprofessional Specialist: Other: Other: Other: Other: MANAGING AGGRESSIVE/ASSULTIVE BEHAVIORS (any behaviors which have the potential of harming the student or others):REVIEW DATE: PARTICIPANTS The names of the participants below indicate that the individuals participated in the development of the Behavior Intervention Plan. Parent and/or student (age 18 or older) consent is on page 3.NAME OF PARTICIPANT RELATIONSHIP TO STUDENTAFTER REVIEWING THE INFORMATION, INDICATE YOUR RESPONSE BY CHECKING THE APPROPRIATE SPACE AND SIGN BELOW: I GIVE PERMISSION TO IMPLEMENT THE BEHAVIOR INTERVENTION PLAN. I DO NOT GIVE PERMISSION TO IMPLEMENT THE BEHAVIOR INTERVENTION PLAN.______PARENT SIGNATURE DATECONFIDENTIAL Page 12 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:BEHAVIORAL INTERVENTION PLAN REVIEWSTUDENT: DATE: SUMMARIZE TARGETED AND REPLACEMENT BEHAVIORS: HAS THERE BEEN AN INCREASE, DECREASE, OR NO CHANGE IN THE TARGETED BEHAVIOR: ARE THE SUPPORTS/INTERVENTIONS APPROPRIATE? YES NO IF NO, WHAT MODIFICATIONS/ADDITIONS NEED TO BE MADE TO CURRENT PLAN:REVIEW DATE: PARTICIPANTS The names of the participants below indicate that the individuals participated in the review of the Behavior Intervention Plan. Parent and/or student (age 18 or older) consent is on page 3.NAME OF PARTICIPANT RELATIONSHIP TO STUDENTAFTER REVIEWING THE INFORMATION, INDICATE YOUR RESPONSE BY CHECKING THE APPROPRIATE SPACE AND SIGN BELOW: I GIVE PERMISSION TO IMPLEMENT THE BEHAVIOR INTERVENTION PLAN. I DO NOT GIVE PERMISSION TO IMPLEMENT THE BEHAVIOR INTERVENTION PLAN.______PARENT SIGNATURE DATECONFIDENTIAL Page 13 R12/21/11 MECKLENBURG COUNTY PUBLIC SCHOOL FUNCTIONAL BEHAVIOR ASSESSMENT(FBA)/BEHAVIOR INTERVENTION PLAN (BIP) STUDENT’S FULL DATE OF INITIALMEETING: NAME: DATE FBA/BIP REVIEWEDSCHOOL: DOB: GRADE: GENDER: AGE:PERMISSION TO CONDUCT A FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA) A BEHAVIOR IMPROVEMENT PLAN (BIP)FBA & BIPPARENTAL /ADULT STUDENT CONSENT FOR INDIVIDUAL EVALUATIONI GIVE PERMISSION for Mecklenburg County Public I DO NOT GIVE PERMISSION for Mecklenburg Schools to proceed with any proposed assessment, as County Public Schools to proceed with the assessment indicated above, of my child to determine the cause of of my child in order to determine the cause of inappropriate behaviors within the school environment and inappropriate behaviors within the school environment to develop a plan to address those behaviors. and to develop a plan to address those behaviors.DATE DATE ______SIGNATURE(S) OF PARENT(S)/GUARDIAN(S)/SURROGATE/ADULT STUDENT SIGNATURE(S) OF PARENT(S)/GUARDIAN(S)/SURROGATE/ADULT STUDENTCONFIDENTIAL Page 14 R12/21/11

Mecklenburg County Public Schools s1

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