Muskegon Area ISD Functional Assessment/Behavior Intervention Form

General Information
Student: K Birthdate: N/A Eligiilit! Status: yes Date: 9/25/12
School: N/A Medication: N/A
"aseload #eacher: Kate Harrison, Hannah Shulz,
Sarah Steed, Jessica Burtka,
Catherine ian!
$revious Funct Assess% &es 'o (hen:
I) Student Strengths* Skills* and Difficulties
+ist Student Strengths
and Skills:
"ein! a leader, hel#$ul, and ha%in! a "i!
#ersonality/stron!&illed
+ist Student
Difficulties:
transitions, dis'issal and structured instruction
classti'e
II) Behavior,s- of "oncern
Descri.tion / 0servale/Measurale
1()elin!, ne!ati%e &ords, tone and %olu'e
2( Cryin! uncontrolla"ly, can last 1*5+ 'inutes
,( -e$usal to co'#ly &ith adult directions daily
.( /0hysical a!ression to&ards adults and #eers/
1s this "eha%ior addressed in the School Hand"ook2 ) N
1o2 0ften Duration Intensit! $rolem has
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daily N/A sho%in!,
sla##in!,
#ushin!
III) Environmental Issues and Situational 4ariales
(hat triggers or causes the ehavior% (hat ha..ens efore the ehavior% 4nstructured ti'es such as lunch/recess, hall&ay,
transitions, Art/05 tri!!er the ne!ati%e "eha%iors(Student is could "e either a!itated or cal' "e$ore the "eha%ior occurs(6hen student recie%es
a &arnin!, does not !et so'ethin! ri!ht in class, lack o$ slee#, doesn7t $eel &ell, chan!es in routine, #eers #ercie%ed o$ "ein! 'ean or un$air,
e8#ected and une8#ected transitions(
(hat ha..ens immediatel! after the .rolem ehavior occurs% ,student reactions* staff reactions* environmental changes-
%er"al #ro'#t, re'o%e $ro' class to take a "reak, re'o%e $ro' class to !o to Assistant 0rinci#les o$$ice, ho'e co''unitcation, 'ake a'ends
In 2hat settings/situations is the ehavior of concern most and least likel! to occur%
Settings/Situations Most +ikel! +east +ikel!
Adults% 9#ersonality characteristics, teachin!
style, !ender, disci#linary style, etc(, no na'es:
;ransitions, Art and 05, <ath, Science and
dis'issal, non classroo'
teacher
&hen adult is !i%in! her a de'and or re=uest,
$eers% ,#ersonality characteristics, !ender,
etc(, no na'es:
Con$lict is likely &ith all #eers N/A
"ertain Activities% 9inde#endent &ork,
lecture, &ritin! acti%ities, s'all !rou#:
Structured and 4nstructured N/A
Settings2 9#lay!round, 'ath, science, lunch,
school "us, unstructured ti'e:
#lay!round, hall&ay, &ith other adults, Art and
05 and lunchroo'
&hen she is her o&n classroo'
#ime of Da! or "lass 9'ornin!, end o$
class, a$ternoon)
all ti'es N/A
0ther% 9ho'e issues, "us, 'edication, health,
slee#, etc(:
N/A &hen she is "ein! a leader
I4) "hild5s E3.osure to 6ules Governing #his Behavior Check >ne or <ore and ist Ho& >$ten
Class ?iscussions 1*1 ?iscussions Beha%ior 0lan
Asse'"lies Hand"ooks 0osted Classroo' -ules
Check Sheet >ther
4) $revious Interventions and Su..orts Check >ne or <ore and 1ndicate 3re=uency
Social 6ork
Su##ort
Con$lict -esolution 0eer <ediation
Beha%ioral Su##ort
Contracts
An!er <ana!e'ent Sta$$/Student A&areness
-e!ardin! B10

>ther
4I) $revious "onse7uences and Disci.linar! Measures Check >ne or <ore and 1ndicate 3re=uency o$ 4se
;i'e >ut -e$erred to >$$ice ?etention
oss o$ 0ri%ile!e
1n*School
Sus#ension/Sus#ension
6ork ?etail/-estitution
0arental Noti$ication Beha%ior 1!nored -e#ri'and/6arnin!
>ther /Attached ?ocu'entation
4II) 'eeds Being Met #hrough #his Behavior Check >ne or <ore and 58#lain
5sca#e/A%oidance
a%oidance o$
di$$icult acti%ities
Attention rando' out"urts
58#ression o$
An!er/3rustration

Sensory Sti'ulation 0o&er/Control
&ants to !ain control
o%er #eers and adults
;an!i"le
-elie$ o$ 3ear/An8iety >ther
4III) Goal to A..ro.riatel! Address 'eed,s-
Goal: ;he student &ill learn to e8#ress their $eelin!s in a##ro#riate &ays "y ?ece'"er 2+12(
I8) $referred Activities and 6einforcers
+ist .referred activities@ &orkin! on the co'#uter, hel#in! &ith
classroo' errands and tutorin! youn!er students
+ist .referred reinforcers@ %ideos, toys, ceti$icates, lunch &ith teacher
8) Skills 'eeded to e #aught to 6e.lace Behavior of "oncern
6hat Beha%iors ?o )ou 6ant the Student to 5n!a!e in to -e#lace the Beha%ior2
#eer to #eer and student to teacher co'unication skills, co#in! skills, #ro"le' sol%in! skills and cal'in! strate!ies(
8I) Behavior $lan
$reventative Strategies
Classroo' Acco''odations, A##roach
Strate!ies, Seatin! Arran!e'ents, 1nstructional
Strate!ies, etc(
6einforcement Strategies
<ethods o$ ;eachin! and -ein$orcin!
A##ro#riate/-e#lace'ent Skills
$rocedures to Follo2 (hen
Behavior 0ccurs
S#eci$ic Ste#s to ;ake 6hen Beha%ior >ccurs
close #ro8i'ity to a teacher, &arnin!
"e$ore s&itchin! to ne& acti%ity,
di$$erentiate lesson #lans to "e 'ore
structured $or K
!i%e K 0A;, run errands, eatin! lunch
&ith the teacher
1( re'o%e K $ro' situation &ith #eer or
adult to cool do&n area
2(discuss &hy "eha%ior occurred
9con%ersation:
,("rainstor' &ith K alternate &ays to
e8#ress and 'ana!e her e'otions
and
.(&ith K discuss a##ro#riate
conse=uence and carry it out
.( <ake a'ends &ith #eer or adult
5( Ai%e conse=uence i$ needed
Deviation of School 1andook%
)es No
8II) Data "ollection
Descrie ho2 s!stematic/measurale data 2ill e collected for Behavior $lan:
;he tri!!er, "eha%ior, res#onse and ti'e &ill "e recorded
Attach Sam.le Data Sheet
&ill in$or' the $ollo&in! sta$$ o$ B10@
Si!natures "elo& indicate the #lan has "een re%ie&ed and a!reed u#on $or i'#le'entation@
$arent/Guardian #eacher
Social (orker/$s!chologist S.ecial Education #eacher
Student Administrator
0ther 0ther
?ate9s: #lan re%ie&ed@ ?ate #lan ter'inated@
/Attach'ents B 'ay include #oint sheets, contracts, token cards,
#ro!ress notes, re$errals, #arent contacts(
<A1S? 2/++