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Positive Behavior Support Plan
(Form very similar to that used by Southwest SELPA)
Name: ___________________________________________
IEP/
“504”: date:____________________________
Behavior
impacting learning is:
_____________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
It impedes
learning because:
________________________________________________________
_________________________________________________________________________________
Estimate of
current severity of behavior problem: ______________________________________
Current
frequency / intensity / duration of behavior:
____________________________________
Current
predictors for behavior: _____________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What should
student do instead of this behavior: _______________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What
supports the student using the problem behavior:
_________________________________
_________________________________________________________________________________
Behavioral
Goals/ Objectives related to this plan: _______________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Teaching
Strategies for new behavior instruction:_______________________________________
_________________________________________________________________________________
_________________________________________________________________________________
___________________________________________________________________
By:
_____________________________________Frequency:
______________________________
Environmental
structure and supports, time/space/materials/interactions:__________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
By:
____________________________________Who
monitors?____________________________
Reinforcers/
rewards: ______________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
By:________________
Frequency________________ By:
_________________________________
Reactive
strategy to employ if behavior occurs again:
____________________________________
_________________________________________________________________________________
By: _____________________________________________________________________________
Monitoring
results and communication: options: daily,
weekly reports, _____________________
_________________________________________________________________________________
(Working document for in-services on
behavior, Diana Browning Wright, So. Cal. Diagnostic Center, CA. Dept.
of Education)
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