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Appendix B
Positive Behavioral Intervention Plan
Planning Form - Blank

IEP teams can use this form to guide them through the process of developing the Positive Behavioral Intervention Plan. Please note that two sample planning forms are available here - Case Study 1 and Case Study 2

Student _________________________________________ Age __________ Sex ___________
Teacher(s) _____________________________________________ Grade _________________
Case Manager __________________________________________ Date(s) ________________

Reason for intervention plan:

 

 

Participants (specify names):

( ) student___________________________
( ) family member ____________________
( ) special educator____________________
( ) general educator ___________________
( ) peer(s) ___________________________
( ) special education administrator_______________
( ) general education administrator ______________
( ) school psychologist________________________
( ) other agency personnel_____________________
_______________________________________
( ) other (specify) _________________________________________________________________
________________________________________________________________________________

 

Fact Finding

  1. General learning environment: Describe the student’s school class schedule, including any special programs or services.
  2.  

     

     

  3. Problem behavior: Define the problem behavior(s) in observable, measurable, and countable terms (i.e., topography, event, duration, seriousness, and/or intensity). Include several examples of the behavior.
  4.  

     

     

  5. Setting events: Describe important things that are happening in the student’s life that may be causing the behavior(s) of concern.
  6.  

     

  7. Review existing data: Summarize previously collected information (records review, interviews, observations, and test results) relevant to the behavior(s). Attach additional sheets if necessary.
  8.  

     

    Possible Explanations

  9. Identify likely antecedents (precipitating events) to the behavior(s).
  10.  

     

  11. Identify likely consequences that may be maintaining the behavior(s).
  12.  

     

  13. Identify and describe any academic or environmental context(s) in which the problem behavior(s) does not occur.
  14.  

     

    Validation

  15. Functional assessment: Do you already have enough information to believe that the possible explanations are sufficient to plan an intervention?
    1. If yes, go to Step 9, if no, then what additional data collection is necessary?
    2. ( ) Review of IEP goals and objectives
      ( ) Review of medical records
      ( ) Review of previous intervention plans
      ( ) Review of incident reports
      ( ) ABC (across time and situations)
      ( ) Motivational analysis
      ( ) Ecological analysis
      ( ) Curricular analysis
      ( ) Scatter plot
      ( ) Parent questionnaire/interview
      ( ) Student questionnaire/interview
      ( ) Teacher questionnaire/interview (specify who) ______________________
      ( ) Other (explain) _______________________________________________

    3. Summarize data. Attach additional sheets if necessary.

     

     

     

    Planning

  16. Formulate hypothesis statement: Using the table below, determine why the student engages in problem behavior(s), whether the behavior(s) serves single or multiple functions, and what to do about the behavior(s).
  17.  

    Internal

    External

     

    Obtain Something

     

     

     

     

     

     

    Avoid Something

     

     

     

     

     

     

  18. Current level of performance: Describe problem behavior(s) in a way the team will recognize onset and conclusion of behavior.
  19.  

     

  20. Describe replacement behavior(s) that are likely to serve the same function as the behavior(s) identified in Step 9.
  21.  

     

  22. Measurement procedures for problem behavior(s) and replacement behavior(s):
    1. Describe how (e.g., permanent products, event recording, scatterplot), when, and where student behavior(s) will be measured.
    2.  

       

       

    3. Summarize data by specifying which problem behavior(s) and replacement behavior(s) will be targets for intervention.

     

     

  23. Behavioral intervention plan:
    1. Specify goals and objectives (conditions, criteria for acceptable performance) for teaching the replacement behavior(s).
    2.  

    3. Specify instructional strategies that will be used to teach the replacement behavior(s).
    4.  

       

    5. Specify strategies that will be used to decrease problem behavior(s) and increase replacement behavior(s).
    6.  

       

    7. Identify any changes in the physical environment needed to prevent problem behavior(s) and to promote desired (replacement) behavior(s), if necessary.
    8.  

       

    9. Specify extent to which intervention plan will be implemented in various settings; specify settings and persons responsible for implementation of plan.

     

     

  24. Evaluation plan and schedule: Describe the plan and timetable to evaluate effectiveness of the intervention plan.
    1. Describe how, when, where, and how often the problem behavior(s) will be measured.
    2.  

       

    3. Specify persons and settings involved.
    4.  

       

    5. Specify a plan for crisis/emergency intervention, if necessary
    6.  

       

    7. Determine schedule to review/modify the intervention plan, as needed. Include dates and criteria for changing/fading the plan.

     

     

  25. Describe plan and timetable to monitor the degree to which the plan is being implemented.

 

 


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