ASK - Advocates for Special Kids
"Parents helping parents to understand special education"

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Positive Behavior Plan Samples and Templates


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)


Copyright 2001  ASK 
All rights reserved.
Revised: January 25, 2002


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