Wilkes County Schools

Behavior Intervention Planning Form

Student: _______________________ DOB:__________________________ Date: ______________
Teacher: _______________________ Grade: ____________ School: ________________________
Student Strengths:
1)
2)
3)
With which adult(s) does the student have a positive relationship at school? ____________________
__________________________________________________________________________________

Identify Behaviors of Concern. List target behaviors that disrupt students learning of the learning of
others:
1)
2)

Summarize data on target behavior including patterns, if any.
Attach data collection forms; interview documents; observational forms; history of school problems; etc.
Collect Baseline Data on target behaviors for 2 weeks.

Additional Information Attached. List:


Describe any situational events:
These are time bound events (e.g. divorce, new student in the class, foster home placement) that may
be influencing the childs behavior at the present time.


Behavior Intervention Planning Form Page 2
Context: Where, what, when and with whom? Check all that apply and fill in the blank.
Setting Events:
o Response to demand/request
o Transition between tasks/setting instruction
o Interruption in routine
o Negative consequences for behavior _____________________________________
o External (bus, hall, bathroom, home, other adult, teacher, staff, substitute teacher)
o Specific activity _______________________________________________________
o Presence or absence/interaction of a specific peer:__________________________
o Independent seat work
o Small group
o Large group
o Unstructured activity
o Specific time of day/week________________________________________________
o Specific subject_________________________________________________________
o Other _________________________________________________________________
Physiological/Emotional Factors:
o Medication (change/not taking) ___________________________________________
o Lack of social attention __________________________________________________
o Medical condition/diagnosis ______________________________________________
o Social skills deficit _______________________________________________________
o Negative social interaction with ___ Peers ___ Adults
o Change in ___Home/family dynamics ___ Eating/diet routine ___Sleep patterns
o Other __________________________________________________________________
Environmental:
o Over-stimulation in classroom (noise, visual, materials, movement, lighting)
o Seating arrangements/grouping
o Proximity to teacher/others (personal space).
Describe:_______________________________________________________________
o Crowded setting (cafeteria, hallway, assemblies, etc.)
o Frequent disruptions (bells, announcements, visitors, etc.)
o Other _________________________________________________________________


Behavior Intervention Planning Form/Functional Behavior Assessment Page 3
Academics/Instruction:
o Grade level-Reading ___ On ___ Above ___ Below
o Grade level-Math ___ On ___ Above ___ Below
o Grade level-Written language ___ On ___ Above ___ Below
o Activities: ___ Too Easy ___ Too Difficult
o Work Completion: ___ Finishes quickly ___ Average ___ Rarely finishes
o Directions ___ Too Many ___ Too long ___ Processes slowly
o Student learning style: ___ Auditory ___ Visual ___ Hands on
o Difficulty organizing materials and/or activities
o Other _________________________________________________________________
Define the Function of the Behavior:
To Gain:
o Attention from ___ Peers ___ Staff ___ Preferred adult
o Desired item or activity
o A choice
o Sensory input
o Other _______________________________________________________________________
To Avoid:
o To escape or avoid a task student considers: 1) too hard, 2) too long, 3) not meaningful
o To avoid or protest a demand, request or reprimand
o To escape an environment in which the student is overwhelmed or overstimulated
o To escape or avoid specific people or activities
o Other ________________________________________________________________________
Hypothesis:
What we think the student is doing and why s/he is doing it. What reinforces this behavior? Example:
When ________________________ is _____________________________________________________
And_________________________________________________________________________________
Happens, s/he typically responds by ______________________________________________________
To gain ______________________________________________________________________________.


Behavior Intervention Plan Page 4
Target Behavior: What specific behavior disrupts the students learning or causes classroom
disruptions?
1)
2)
Desired Behavior: What alternative behaviors do we want to see the student perform in place of the
problem behavior?
1)
2)
Teaching Strategies/Interventions: What skills will be taught to the student which serve the same
function as the undesired behavior?





How will these skills be taught? (Modeling, role play, performance feedback, generalization and
maintenance). Persons responsible.









What changes will be made in the environment/curriculum to decrease the likelihood the undesirable
behavior will occur?




Behavior Intervention Plan Page 5
Responses to desired and undesired behaviors.
Rewards-What will motivate the student to perform the desired behavior? (Complete reinforcer survey):





Consequences-Describe clear, enforceable consequences related to the behavior:





Crisis Plan:





Behavior Plan Review Date: _____________________________________________________________