Functional Behavioral Assessment and Behavioral Intervention Plan RtI Tier 3 - Comprehensive Page ___ of ___ Student: Student #: D.O.B: School: Exceptionalities: Grade: Date of Report: Team Members (those involved in assessment/interventions) Records Review: (check those which apply) Name Academic/Cum/Audit Disciplinary Records Anecdotal Records Evaluations/Assessments Previous Interventions Progress Notes to Family Child Study Team Notes Samples of Student’s Work Other: Title Records reviewed by: Relevant Information: (obtained from records review, interviews, and/or direct observations) Brevard Public Schools Rational for Assessment and Interventions Student is engaging in behavior that places the student or others at risk of harm and/or results in substantial property damage. Behavioral concerns are resulting in exclusion from participation in activities or settings with peers. Educational team is considering a more restrictive placement due to behavior concerns. Current intervention involves excessively intrusive interventions (e.g. restraint, isolation.) Student’s behavioral difficulties persist despite consistently implemented behavior management strategies based on a less comprehensive or systematic assessment. Other: Student Strengths/Assets: Motivators/Reinforcers: Review of FBA/BIP: (signature and date) Revised 07-07-10 FBA/BIP - Comprehensive

Functional Behavioral Assessment Brevard Public Schools Student: Student #: Date: School: Page ___ of ___ Target behavior #1: Define target behavior: (What does it look like?) How often does it occur? (i.e. 2 x’s a day, 5 x’s per week) How long does it last? (i.e. 3-5 minutes, 30 seconds) Severity of behavior: Mild: Little risk to property or health/disruption to class 5 minutes or less per hour Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour Situations when the behavior is most likely to occur: (i.e. times of day, activity, subject, specific people present) Situations when the behavior is least likely to occur: (i.e. times of day, activity, subject, specific people present) Functional Behavioral Assessment Brevard Public Schools Antecedents: What happens immediately before the target behavior occurs? Consequences: What happens immediately after the target behavior occurs? Function/purpose of behavior: (Specify/Describe) Preferred items/materials Preferred activities Preferred people/social situations Student receives access to: Student avoids/escapes: Student receives attention (+/-) from peers Student receives attention (+/-) from adults Behavior is self stimulating/entertaining and/or feels good Behavior relieves discomfort or pain (Specify/Describe) Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations Revised 07-07-10 FBA/BIP - Comprehensive

Functional Behavioral Assessment Brevard Public Schools Student: Student #: Date: School: Page ___ of ___ Target behavior #2: Define target behavior: (What does it look like?) How often does it occur? (i.e. 2 x’s a day, 5 x’s per week) How long does it last? (i.e. 3-5 minutes, 30 seconds) Severity of behavior: Mild: Little risk to property or health/disruption to class 5 minutes or less per hour Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour Situations when the behavior is most likely to occur: (i.e. times of day, activity, subject, specific people present) Situations when the behavior is least likely to occur: (i.e. times of day, activity, subject, specific people present) Functional Behavioral Assessment Brevard Public Schools Antecedents: What happens immediately before the target behavior occurs? Consequences: What happens immediately after the target behavior occurs? Function/purpose of behavior: (Specify/Describe) Preferred items/materials Preferred activities Preferred people/social situations Student receives access to: Student avoids/escapes: Student receives attention (+/-) from peers Student receives attention (+/-) from adults Behavior is self stimulating/entertaining and/or feels good Behavior relieves discomfort or pain (Specify/Describe) Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations Revised 07-07-10 FBA/BIP – Comprehensive

Functional Behavioral Assessment Brevard Public Schools Student: Student #: Date: School: Page ___ of ___ Target behavior #3: Define target behavior: (What does it look like?) How often does it occur? (i.e. 2 x’s a day, 5 x’s per week) How long does it last? (i.e. 3-5 minutes, 30 seconds) Severity of behavior: Mild: Little risk to property or health/disruption to class 5 minutes or less per hour Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour Situations when the behavior is most likely to occur: (i.e. times of day, activity, subject, specific people present) Situations when the behavior is least likely to occur: (i.e. times of day, activity, subject, specific people present) Functional Behavioral Assessment Brevard Public Schools Antecedents: What happens immediately before the target behavior occurs? Consequences: What happens immediately after the target behavior occurs? Function/purpose of behavior: (Specify/Describe) Preferred items/materials Preferred activities Preferred people/social situations Student receives access to: Student avoids/escapes: Student receives attention (+/-) from peers Student receives attention (+/-) from adults Behavior is self stimulating/entertaining and/or feels good Behavior relieves discomfort or pain (Specify/Describe) Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations Revised 07-07-10 FBA/BIP - Comprehensive

Functional Behavioral Assessment Brevard Public Schools Student: Student #: Date: School: Page ___ of ___ Target behavior #4: Define target behavior: (What does it look like?) How often does it occur? (i.e. 2 x’s a day, 5 x’s per week) How long does it last? (i.e. 3-5 minutes, 30 seconds) Severity of behavior: Mild: Little risk to property or health/disruption to class 5 minutes or less per hour Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour Situations when the behavior is most likely to occur: (i.e. times of day, activity, subject, specific people present) Situations when the behavior is least likely to occur: (i.e. times of day, activity, subject, specific people present) Functional Behavioral Assessment Brevard Public Schools Antecedents: What happens immediately before the target behavior occurs? Consequences: What happens immediately after the target behavior occurs? Function/purpose of behavior: (Specify/Describe) Preferred items/materials Preferred activities Preferred people/social situations Student receives access to: Student avoids/escapes: Student receives attention (+/-) from peers Student receives attention (+/-) from adults Behavior is self stimulating/entertaining and/or feels good Behavior relieves discomfort or pain (Specify/Describe) Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations Revised 07-07-10 FBA/BIP - Comprehensive

Behavioral Intervention Plan Brevard Public Schools Student: Student #: Date: School: Page ___ of ___ Preventative Interventions: What environmental adjustments will be used to make the student’s problem behavior no longer necessary? Modifying physical settings or routines Modifying staff approaches Clarifying expectations New processes of monitoring/reporting progress Behavioral Intervention Plan Brevard Public Schools Interventions for Replacement Behaviors: What behaviors will you teach so that the student no longer needs to engage in the target behavior(s) to get this need met? Revised 07-07-10 FBA/BIP - Comprehensive

Behavioral Intervention Plan Brevard Public Schools Student: Student #: Date: School: Page ___ of ___ Functional Interventions: How will the environment change when the student engages in the desired replacement behavior(s)? How will the environment change when the student engages in the problem behavior? Student will receive access to preferred items, activities, social situations Positive attention from others Free time Tokens, stickers, special recognition Student is ignored Student not permitted access to preferred items, activities, social situations Behavioral Intervention Plan Brevard Public Schools Crisis Management Plan: District approved Crisis Prevention and Intervention (CPI) techniques will be used as warranted to prevent crisis situations from arising, facilitate de-escalation of potentially dangerous behavior, and to ensure safety of self and others. Monitoring (Who and how will data be collected to assess Response to Intervention?): Evaluation (Who and when will the Behavioral Intervention Plan be reviewed and/or revised? Teacher will maintain daily data collection on form attached. Child Study/IEP Team will review data and modify interventions in this plan: as needed to ensure progress. (when) Revised 07-07-10 FBA/BIP - Comprehensive

Brevard Public Schools Page ___ of ___ Data Collection RE: Target Behavior # ____ Data Collection RE: Replacement Behavior Definition of Replacement Behavior: Brevard Public Schools

Brevard Public Schools Page ___ of ___ Data Collection RE: Target Behavior # ____ Data Collection RE: Replacement Behavior Definition of Replacement Behavior: Brevard Public Schools