Muskegon Area ISD Functional Assessment/Behavior Intervention Form

General Information
Student: K Birthdate: Eligiilit! Status: Date: September
25, 2014
School: Medication:
"aseload #eacher: $revious Funct Assess% &es 'o (hen:
I) Student Strengths* Skills* and Difficulties
+ist Student Strengths
and Skills:
Leadership, helpful, having a big personality /
strong will, able to disuss feelings when
alm, demonstrates pride and loves herself
+ist Student
Difficulties:
!elling and disrespet towards adults and peers,
physial aggression towards adults and peers, rying
unontrollably, refusal to omply to adult diretion
II) Behavior,s- of "oncern
Descri.tion / 0servale/Measurale
!elling at adults and peers using negative words, tone, and volume"
#s this behavior addressed in the Shool $andboo%& ! '
1o2 0ften Duration Intensit! $rolem has
E
3
i
s
t
e
d
,l
e
n
g
t
h
o
f
ti
m
e
-
u
n
%
n
o
w
n
(aily 1 min to 50
min
moderate
to severe
III) Environmental Issues and Situational 4ariales
(hat triggers or causes the ehavior% (hat ha..ens efore the ehavior% )ransistions in the hallway, art, *"+, math, siene,
and dismissal"
(hat ha..ens immediatel! after the .rolem ehavior occurs% ,student reactions* staff reactions* environmental changes-
,erbal prompt, removal from lass to ta%e a brea%, removal from lass to go to -ssistant *rinipal.s offie, home ommuniation, ma%e amends
In 2hat settings/situations is the ehavior of concern most and least likel! to occur%
Settings/Situations Most +ikel! +east +ikel!
Adults% /personality harateristis, teahing
style, gender, disiplinary style, et", no names0
1en +d and Speials teahers -dministration
$eers% ,personality harateristis, gender,
et", no names0
*eers interated with during unstrutured
settings /lunh, hallway, reess et"0
*eers interated with during strutured times
"ertain Activities% /independent wor%,
leture, writing ativities, small group0
2nstrutured times /reess, lunh, hallway
transitions0
Language -rts, strutured times
Settings& /playground, math, siene, lunh,
shool bus, unstrutured time0
$allway, art, *"+, math, siene, dismissal Language arts, soial studies, musi
#ime of Da! or "lass /morning, end of
lass, afternoon)
dismissal, morning afternoon
0ther% /home issues, bus, mediation, health,
sleep, et"0
la% of sleep, doesn.t feel well, hange in level
on level system

I4) "hild5s E3.osure to 6ules Governing #his Behavior 3he% 4ne or 5ore and List $ow 4ften
3lass (isussions 161 (isussions 7ehavior *lan
-ssemblies $andboo%s *osted 3lassroom 8ules
3he% Sheet 4ther
4) $revious Interventions and Su..orts 3he% 4ne or 5ore and #ndiate 9re:ueny
Soial ;or%
Support
3onflit 8esolution *eer 5ediation
7ehavioral Support
3ontrats
-nger 5anagement Staff/Student -wareness
8egarding 7#*

4ther
4I) $revious "onse7uences and Disci.linar! Measures 3he% 4ne or 5ore and #ndiate 9re:ueny of 2se
)ime 4ut 8eferred to 4ffie (etention
Loss of *rivilege
#n6Shool
Suspension/Suspension
;or% (etail/8estitution
*arental 'otifiation 7ehavior #gnored 8eprimand/;arning
4ther <-ttahed (oumentation
4II) 'eeds Being Met #hrough #his Behavior 3he% 4ne or 5ore and +=plain
+sape/-voidane -ttention
+=pression of
-nger/9rustration
2nontrollabl
e situations
and times of
the day lead
the student to
e=press
anger in the
form of
refusal and
yelling
Sensory Stimulation *ower/3ontrol
-ts out during
transitions and refusal
to omply to authority
demonstrate her need
to be in harge and to
have things her own
way
)angible
8elief of 9ear/-n=iety 4ther
4III) Goal to A..ro.riatel! Address 'eed,s-
Goal: 7y >une 2015, K will use strategies to appropriately ommuniate with adults and peers, as doumented by the behavior log"
I8) $referred Activities and 6einforcers
+ist .referred activities? 8ole as a leader in lass situtaions, as%ing
student to run a lassroom errand
+ist .referred reinforcers? 4ne on one time with staff or peers
8) Skills 'eeded to e #aught to 6e.lace Behavior of "oncern
;hat 7ehaviors (o !ou ;ant the Student to +ngage in to 8eplae the 7ehavior&
3ommuniation s%ills, oping s%ills and problem solving s%ills "
8I) Behavior $lan
$reventative Strategies
3lassroom -ommodations, -pproah
Strategies, Seating -rrangements, #nstrutional
Strategies, et"
6einforcement Strategies
5ethods of )eahing and 8einforing
-ppropriate/8eplaement S%ills
$rocedures to Follo2 (hen
Behavior 0ccurs
Speifi Steps to )a%e ;hen 7ehavior 4urs
Sitting near the teaher, set shedule,
routines, lassroom meetings
8eplae negative words with more
appropriate words, have student write
down the outbursts that they would
have otherwise verablly ommuniated
/outburst noteboo%0 and review with
teaher when ready
10 3lose pro=imity and get down to her
level
20 ,erbal prompt
@0 (iret her to the outburst noteboo%
and allow time to write
40 8emove from lass to ta%e a brea%
50 )eaher review noteboo% with
student and give her time to
ommuniate emotions
Deviation of School 1andook%
!es 'o
8II) Data "ollection
Descrie ho2 s!stematic/measurale data 2ill e collected for Behavior $lan:
;hole 3lass? 3lass (oAo will allow for the teaher to award points to K when she is effetively ommuniating, using appropriate oping s%ills and
problem solving" )his will also allow guardians to he% in on K.s progress through the app" )eaher will be able to %eep reord of when outbursts our"

Attach Sam.le Data Sheet
will inform the following staff of 7#*?
Signatures below indiate the plan has been reviewed and agreed upon for implementation?
$arent/Guardian #eacher
Social (orker/$s!chologist S.ecial Education #eacher
Student Administrator
0ther 0ther
(ate/s0 plan reviewed? (ate plan terminated?
<-ttahments B may inlude point sheets, ontrats, to%en ards,
progress notes, referrals, parent ontats"
5-#S( 2/00