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General Information
Student:
Birthdate:
School:
Caseload Teacher:
Eligibility Status:
Date:
Medication:
ASD
Yes
No
When:
List Student
Difficulties:
How Often
3-4 times a
day
Duration
could
involve
multiple
grabs in a
single
event; lasts
until his
needs are
met
Intensity
intense
enough
to elicit
an
emotiona
l
response
from
recipient
Problem has
E
x
i
s
t
e
d
(l
e
n
g
t
h
o
f
ti
m
e
)
throughout his
y
e
a
r
s
t
h
a
t
h
e
h
a
s
b
e
e
n
i
n
s
c
h
o
o
l.
What triggers or causes the behavior? What happens before the behavior?
outdoor recess is cancelled due to weather
the swing is not available at sensory time
his routine is changed or interrupted
he is working with an unfamiliar person (such as a substitute)
requested a schedule change that did not get changed (something that he wants that does not go according to plan)
In what settings/situations is the behavior of concern most and least likely to occur?
Settings/Situations
Most Likely
Least Likely
Adults?
Certain Activities?
(independent work,
lecture, writing activities, small group)
Settings?
Class Discussions
1-1 Discussions
Assemblies
Handbooks
Check Sheet
Other
Social Work
Support
Behavioral Support
Contracts
Other
Conflict Resolution
Anger Management
Staff/Student Awareness
Regarding BIP
Loss of Privilege
Parental Notification
Other
Referred to Office
In-School
Suspension/Suspension
Behavior Ignored
Detention
Work Detail/Restitution
Reprimand/Warning
*Attached Documentation
Attention
Sensory Stimulation
Power/Control
Relief of Fear/Anxiety
Other
When J is feeling angry or upset, he will grab a designated rather than a person's arm.
Reinforcement Strategies
Signatures below indicate the plan has been reviewed and agreed upon for implementation:
Parent/Guardian
Teacher
Social Worker/Psychologist
Student
Administrator
Other
Other