<p> Chandler Unified School District Positive Behavior Intervention Plan</p><p>Student Name: Home Phone: Date: Date of Birth: Home Address: Student No:</p><p>Age Gender Grade Home School Attending School</p><p>Ethnicity Primary Language/Date Home Language/Date Determined Determined</p><p>Parent/Guardian Name Home Phone Parent/Guardian Name Home Phone</p><p>Address Work Phone Address Work Phone</p><p>Emergency Phone Emergency Phone</p><p>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.)</p><p>Team members who participated in developing the plan Positions Names</p><p>Student Parent/Guardian Case Manager Psychologist General Education Teacher Other: Other: </p><p>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?)</p><p>III. Identified Positive Reinforcers (Based upon administration of a positive reinforcer survey, parent input, student interview, etc.)</p><p>IV. Environmental Strategies/Supports to be Implemented (considerations but not exclusive nor exhaustive)</p><p>Strategy/Support Frequency Person Responsible</p><p>V. Instructional Strategies to be Implemented (considerations but not exclusive nor exhaustive)</p><p>Strategy Frequency Person Responsible</p><p>VI. Implementation Plan</p><p>When Student Does… Frequency Student will Earn… Person Responsible</p><p>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.)</p><p>VIII. Materials Needed to Implement Plan, If Applicable</p><p>Materials Needed Person Responsible for Obtaining/Creating</p><p>IX. Monitoring Person to manage BIP and collect data Data will be collected: and reviewed: Date of BIP Inititation:</p><p>IEP amended and PWN completed and attached to IEP Date:</p><p>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)</p><p>Date of 1st BIP Review Meeting:</p><p>Team Members [and position] Attending: Discussion of Student Progress and Recommendations:</p><p>Projected Date of Next Review, if applicable:</p><p>Date of 2nd BIP Review Meeting:</p><p>Team Members [and position] Attending: Discussion of Student Progress and Recommendations:</p><p>Projected Date of Next Review, if applicable:</p><p>Date of 3rd BIP Review Meeting:</p><p>Team Members [and position] Attending: Discussion of Student Progress and Recommendations:</p><p>Projected Date of Next Review, if applicable:</p>