FORM 1: BEHAVIOR IDENTIFICATION

School:
Grade: 3
Teacher:
Educational Placement: Functional Skills
Diagnosis/Eligibility: Autism

Student Name: Katelyn

Date of Birth: Click here to enter a date.
Gender: Female
Parent/Guardian: Click here to enter text.
Data Sources:
Observation

Student Interview

Teacher/Staff Interview

Parent Interview

Rating Scales

Normative Testing

Other: Click here to enter text.

Behavior Description:
Primary Cause of Concern:
When Katelyn gets frustrated she will escalate and pull hair. She will
target one paraprofessional, Beth. She will typically start singing Old McDonald very loudly and then get up from
wherever she is and try to grab the hair of someone that will give her an exuberant response.
Primary Impact of Behavior:
Multiple staff members are required to help calm her down and
prevent harm to other students.
Target Behavior:
Pulling Hair.

Settings in which Behavior occurs (all that apply):

Classroom
Recess
Hallway
Bathroom
Store
Family time
Other: Lunch Time.

Bedroom
Family Room
Kitchen/dining
Car/bus
Group activity
Alone time

Measurement Paradigm:
Frequency: This behavior occurs 11 times every week.
Choose an item.
Ratio:
This behavior occurs 75 % of the times when my student is in groups with Beth.

FORM 2.1: BEHAVIORAL TRACKING-FREQUENCY

Target Behavior: Hair Pulling.

Date (or Time)
1/4/2016
1/5/2016
1/6/2016
1/7/2016
1/8/2016
1/12/2016
1/13/2016

# of Target Behavior
6
8
2
2
2
1
2

1/14/2016

11

1/19/2016

1/20/2016

1/21/2016

1/25/2016

1/27/2016

2/1/2016

2/2/2016

2/16/2016

Date (or Time)

2/17/2016
2/23/2016
2/24/2016
3/1/2016
3/2/2016
3/7/2016
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.

# of Target Behavior
1
3
4
3
1
1
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.

FORM 3: ANTECEDENT-BEHAVIOR-CONSEQUENCE
Student Name:
Form Completed By:
Target Behavior
DATE

TIME

Katelyn Curtis
Tori Stanley
Hair Pulling

SETTING

1/4/2016 11:05

Lunch

Sammie

ANTECEDENTS
(BEFORE)
Walking to lunch

1/4/2016 1:05

School

Beth

Story

Hair pull

No, Hands to self

1/4/2016 1:15

School

Toni

Story in seat

Hair Pull (3)

No, Hands to self

1/4/2016 2:45

School

Scarlett

In line- end of day

Hair pull

No, Hands to self

Hair pull (2)Hair pull

(2)Hair pullHair
pullHair pullHair pull

No, Hands to self

Hair pull

No + social story

Hair pull

No

1/5/2016 8:409:201:001:051:501:54 School

PEOPLE
PRESENT

Date:
2/15/2016
Position: Student Teaching

BethKarenSammieBethJaydenDaniel Announcements,
ipad, story

BEHAVIOR
Hair pull

CONSEQUENCES
(AFTER)
No, Hands to self

Lining up from recess

1/8/2016 8:35

School

Toni

1/8/2016 10:55

School

Sammie

PE
MARS

Transition from Art

to lunch

DATE

TIME

SETTING

1/12/2016

1:15

Bathroom

PEOPLE
PRESENT
Karen

ANTECEDENTS (BEFORE)

BEHAVIOR

1/13/2016

1:15

School

Nancy

Story ipad on teachers desk

Hair pull

No, Hands to self

1/13/2016

2:17

School

Owen

Beths group

Hair pull

No, Hands to self

1/14/2016

10:45

School

Beth

Beths group with puzzle

Hair pull

No, Hands to self

1/14/2016

12:00

School

OT

OT writing

Hair pull (5)

Sent back to class

1/14/2016

1:50

School

Beth, Toni

Groups- going to Beths

group

Attempts to hit (5)

Finish work + social story

Nice Hands

1/19/2016

8:30

School

Karen

MARS- break finished

Hair pull

No, Hands to self

Going to bathroom

Hair pull

CONSEQUENCES
(AFTER)
No + continue to
bathroom

DATE

TIME

SETTING

1/19/2016

10:43

School

1/20/2016

2:25

School

1/21/2016

10:40

1/25/2016

PEOPLE
PRESENT
Treyson

ANTECEDENTS (BEFORE)

BEHAVIOR

CONSEQUENCES
(AFTER)
Loses 3 minutes of
computers @ desk

Groups- computer

Hair pull

Click here to
enter text.

Groups- computer

Hair pull

No, Hands to self

School

Click here to
enter text.

Groups- movie

Hair pull

No, Hands to self

10:28

School

Click here to
enter text.

Groups- independent

Hair pull

Loses 3 minutes of
computers @ desk

1/27/2016

9:30

School

Sammie

MLA- wiggles out

Hair pull

Loses 3 minutes of recess

2/1/2016

9:12

School

Karen

MLA- break finished

Hair pull

Loses 3 minutes of recess

2/1/2016

1:13

School

Click here to
enter text.

Transition- Groups

Hair pull

DATE

TIME

SETTING

2/2/2016

1:30

School

2/16/2016

1:15

School

2/23/2016

1:15

2/24/2016

PEOPLE
PRESENT
Click here to
enter text.

ANTECEDENTS (BEFORE)

BEHAVIOR

CONSEQUENCES
(AFTER)
Click here to enter text.

Groups- Beths

Hair pull

Click here to
enter text.

News 2 You

Hair pull (2)

Color Change- Loses 3

minutes of computers @
desk

School

Click here to
enter text.

Weekly Reader

Hair pull

Color Change- Loses 3

minutes of computers @
desk

11:20

Lunch

Click here to
enter text.

Lunch

Hair pull

Color Change- Loses 3

minutes of recess

2/24/2016

1:00

School

Click here to
enter text.

Transition from playground

to classroom

Hair pull

Color Change- Loses 3

minutes of computers @
desk

2/24/2016

1:30

School

Library

Hair pull (2)

Color Change- Loses 3

minutes of computers @
desk

FORM 4: FUNCTIONAL BEHAVIOR ASSESSMENT

Student Name:
Form Completed By:
Target Behavior
DATE

1/4/2016

1/5/2016
1/8/2016
1/12/2016
TOTALS
DATE

1/13/2016
1/14/2016

1/19/2016
1/20/2016
TOTALS
DATE

1/21/2016
1/25/2016
1/27/2016
2/1/2016

Katelyn Curtis
Tori Stanley
Hair Pulls

Date:
2/15/2016
Position: Student Teaching

MORNING

TIME
NOON

EVENING

STRUCTURE

ACTIVITY
UNSTRUCTURED

TRANSITION

ATTENTION

FUNCTION
ESCAPE/AVOID
ITEM ACCESS

MORNING

NOON

EVENING

STRUCTURE

UNSTRUCTURED

TRANSITION

ATTENTION

ESCAPE/AVOID

ITEM ACCESS

CONTROL

MORNING

TIME
NOON

EVENING

STRUCTURE

ACTIVITY
UNSTRUCTURED

TRANSITION

ATTENTION

MORNING

NOON

EVENING

STRUCTURE

UNSTRUCTURED

TRANSITION

ATTENTION

ESCAPE/AVOID

ITEM ACCESS

CONTROL

MORNING

TIME
NOON

EVENING

STRUCTURE

ACTIVITY
UNSTRUCTURED

TRANSITION

ATTENTION

FUNCTION
ESCAPE/AVOID
ITEM ACCESS

FUNCTION
ESCAPE/AVOID
ITEM ACCESS

CONTROL

CONTROL

CONTROL

2/2/2016
2/16/2016
2/23/2016
TOTALS
DATE

2/24/2016

Click here
to enter a
date.
Click here
to enter a
date.
Click here
to enter a
date.
TOTALS

MORNING

NOON

EVENING

STRUCTURE

UNSTRUCTURED

TRANSITION

ATTENTION

ESCAPE/AVOID

ITEM ACCESS

CONTROL

MORNING

TIME
NOON

EVENING

STRUCTURE

ACTIVITY
UNSTRUCTURED

TRANSITION

ATTENTION

MORNING

NOON

EVENING

STRUCTURE

UNSTRUCTURED

TRANSITION

ATTENTION

ESCAPE/AVOID

ITEM ACCESS

CONTROL

12

15

15

20

FUNCTION
ESCAPE/AVOID
ITEM ACCESS

CONTROL

FORM 5: IDENTIFYING REPLACEMENT BEHAVIOR

BEHAVIORL INTEVENTION SENTENCE
Our target behavior occurs most often in the Afternoon during structured times for the function of escape or
avoidance.
SUGGESTED INTERVENTION TABLE
TIME/ACTIVITY
POSSIBLE ITNERVENTIONS
/FUNCTION
Morning
-Establish a clear and predictable morning routine or alter the schedule appropriately.
-Ensure that an adequate nights rest is received and alleviate morning chores by completing them the
night before.
Noon
-Explore and manipulate schedules of eating, activity, and rest.
-If appropriate, consider allowing the student an opportunity to contact a caregiver or friend.
Evening
-Determine an appropriate allowance for electronics time and schedule well before bedtime.
-Increase the consistency of each evening by eating, doing chores, and going to bed at the same times.
Structured
-Provide a few Take a Break cards that the student can use to help calm down in a quiet place.
-Consider a reinforcement system with points for each structured activity completed.
Unstructured
-Increase the level of monitoring or supervision, either through an adult or a peer buddy.
-Incorporate periodic check-ins in which the whole class must briefly pause to calm down.
Transition
-Use a visual schedule to remind the student of upcoming events.
-Give prompts during activities that signal a change, beginning with 5 min., 3 min., 1 min., and so on.
Attention
-Allow the student to earn time with a peer or preferred adult.
-Give the student the chance to tell the class a joke or story before the target behavior occurs.
Escape/Avoid
-Allow the student to work towards leaving one minute early or earning free time (group or alone).
-Provide avoidance by reducing the stimuli load by small increments based on good behavior.
Item Access
-Remove the preferred item or activity until the student demonstrates appropriate behavior.
-Allow the student access to the preferred item for a short time prior to demanding activities.
Control
-Provide the student with choices for as many stimuli as possible (even page color can be a choice).
-Allow the student to determine portions of their schedule or their incentive menu often.

Because our target behavior occurs most often in the Afternoon during structured times for the function of escape or
avoidance, we are going to attempt to use the following replacement behaviors:
Replacement Behavior #1:
Replacement Behavior #2:
Replacement Behavior #3:

Allow student to work towards leaving an activity early or else earn choice
the last few minutes of an activity.
Supervise student during all transitions and unstructured activities.
Reinforcement system with points for completed items

activity for

FORM 6: IDENTIFYING BEHAVIORAL GOALS

1. List the Target Behavior

a. Operational Definition: For Katelyn to have nice hands at school, meaning no hair pulling, hitting, or
other forms of physical aggression.

2. How is this behavior measured, and by whom?

a. Measurement Details: Data of aggressive incidents will be taken by Toni and Beth recording when,
where, with whom, and why the aggression seems to have taken place.

3. How is the student able to perform the target behavior currently?

a. Current Functioning: Katelyn averages 11 hair pulls per week since August 2015.

4. How is the student unable to perform the target behavior currently?

a. Current Deficits:
Katelyn is unable to keep nice hands at school when she is frustrated or does
not want to do certain work tasks. She also does not keep hands to self when bored and will pull a
peers hair to gain a reaction from them.

5. How should the students behavior look after the next month, realistically?
a. One Month Goal:
Hair pull incidents should decrease by 2 incidents per week.

6. How should the students behavior look after the next 3 months?
a. Quarter Year Goal:
After 3 months hair pull incidents should be down to 1-2 incidents per week.

7. How should the students behavior look after the next 6 months?
a. Half Year Goal:
After 6 months we should not see hair pulling incidents with the exception of
days of extreme agitation causing the student to escalate once or twice within the course of a month.

8. How should the students behavior look after the next year?
a. Annual Goal:
By the next year hair pulling incidents should be isolated and no longer occur
with frequency. Katelyn will keep nice hands at school and will not exhibit aggression towards peers or
staff.

9. Why is this behavior important for the student to change this behavior?
a. Statement of Need:
Katelyn needs to have nice hands at school in order to be able to work in all
groups and activities to make progress on her IEP goals. She also needs to keep nice hands with peers
so that they are not afraid of her and will be willing to play and interact with her in positive ways.