POSITIVE BEHAVIOR SUPPORTS INTERVENTION

Summary of Student Profile Information

Name:

Date of Birth:

Grade:

Exceptionality:

Summary of 16 questions from Student Profile Information

Parent and Student Interviews

Provide a detailed summary of the parent and student interviews

Summary of Results of Social Skill Checklist and Motivation Assessment Scale

Target Behavior

State the behavior that you want to increase or decrease in one sentence

ABC Charts

Observation 1

A-B-C Recording Form

Date: _____________________Location: ____________________________________

Observer’s name _____________________________Length of time observed: ___________

Observation 2

A-B-C Recording Form

Date: _____________________Location: ____________________________________

Observer’s name _____________________________Length of time observed: ___________

Antecedent, Behavior, Consequence Summary Statement

1. The antecedent is…..

2. The behavior is……

3. The consequence….

Function of the behavior

Based on the ABC charts provided and the results of the Behavior Rating Scale the function of the behavior is……