1. Functional Behavioral Assessment and Behavioral Intervention Plan
RtI Tier 3 - Comprehensive
Page ___ of ___
Student: Student #: D.O.B: School:
Exceptionalities: Grade: Date of Report:
Team Members
(those involved in assessment/interventions)
Records Review:
(check those which apply)
Name
Academic/Cum/Audit Disciplinary Records Anecdotal Records
Evaluations/Assessments Previous Interventions Progress Notes to Family
Child Study Team Notes Samples of Student’s Work Other:
Title
Records reviewed by:
Relevant Information:
(obtained from records review, interviews, and/or direct observations)
Brevard Public Schools
Rational for Assessment and Interventions
Student is engaging in behavior that places the student or others at risk of harm and/or results in substantial property damage.
Behavioral concerns are resulting in exclusion from participation in activities or settings with peers.
Educational team is considering a more restrictive placement due to behavior concerns.
Current intervention involves excessively intrusive interventions (e.g. restraint, isolation.)
Student’s behavioral difficulties persist despite consistently implemented behavior management strategies based on a less comprehensive or systematic assessment.
Other:
Student Strengths/Assets:
Motivators/Reinforcers:
Review of FBA/BIP:
(signature and date)
Revised
FBA/BIP - Comprehensive

2. Functional Behavioral Assessment Brevard Public Schools
Student: Student #: Date: School: Page ___ of ___
Target behavior #1:
Define target behavior: (What does it look like?)
How often does it occur?
(i.e. 2 x’s a day, 5 x’s per week)
How long does it last?
(i.e. 3-5 minutes, 30 seconds)
Severity of behavior:
Mild: Little risk to property or health/disruption to class 5 minutes or less per hour
Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour
Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour
Situations when the behavior is most likely to occur:
(i.e. times of day, activity, subject, specific people present)
Situations when the behavior is least likely to occur:
(i.e. times of day, activity, subject, specific people present)
Functional Behavioral Assessment
Brevard Public Schools
Antecedents:
What happens immediately before the target behavior occurs?
Consequences:
What happens immediately after the target behavior occurs?
Function/purpose of behavior:
(Specify/Describe)
Preferred items/materials Preferred activities Preferred people/social situations
Student receives access to:
Student avoids/escapes:
Student receives attention (+/-) from peers
Student receives attention (+/-) from adults
Behavior is self stimulating/entertaining and/or feels good
Behavior relieves discomfort or pain
(Specify/Describe)
Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations
Revised
FBA/BIP - Comprehensive

3. Functional Behavioral Assessment Brevard Public Schools
Student: Student #: Date: School: Page ___ of ___
Target behavior #2:
Define target behavior: (What does it look like?)
How often does it occur?
(i.e. 2 x’s a day, 5 x’s per week)
How long does it last?
(i.e. 3-5 minutes, 30 seconds)
Severity of behavior:
Mild: Little risk to property or health/disruption to class 5 minutes or less per hour
Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour
Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour
Situations when the behavior is most likely to occur:
(i.e. times of day, activity, subject, specific people present)
Situations when the behavior is least likely to occur:
(i.e. times of day, activity, subject, specific people present)
Functional Behavioral Assessment
Brevard Public Schools
Antecedents:
What happens immediately before the target behavior occurs?
Consequences:
What happens immediately after the target behavior occurs?
Function/purpose of behavior:
(Specify/Describe)
Preferred items/materials Preferred activities Preferred people/social situations
Student receives access to:
Student avoids/escapes:
Student receives attention (+/-) from peers
Student receives attention (+/-) from adults
Behavior is self stimulating/entertaining and/or feels good
Behavior relieves discomfort or pain
(Specify/Describe)
Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations
Revised
FBA/BIP – Comprehensive

4. Functional Behavioral Assessment Brevard Public Schools
Student: Student #: Date: School: Page ___ of ___
Target behavior #3:
Define target behavior: (What does it look like?)
How often does it occur?
(i.e. 2 x’s a day, 5 x’s per week)
How long does it last?
(i.e. 3-5 minutes, 30 seconds)
Severity of behavior:
Mild: Little risk to property or health/disruption to class 5 minutes or less per hour
Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour
Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour
Situations when the behavior is most likely to occur:
(i.e. times of day, activity, subject, specific people present)
Situations when the behavior is least likely to occur:
(i.e. times of day, activity, subject, specific people present)
Functional Behavioral Assessment
Brevard Public Schools
Antecedents:
What happens immediately before the target behavior occurs?
Consequences:
What happens immediately after the target behavior occurs?
Function/purpose of behavior:
(Specify/Describe)
Preferred items/materials Preferred activities Preferred people/social situations
Student receives access to:
Student avoids/escapes:
Student receives attention (+/-) from peers
Student receives attention (+/-) from adults
Behavior is self stimulating/entertaining and/or feels good
Behavior relieves discomfort or pain
(Specify/Describe)
Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations
Revised
FBA/BIP - Comprehensive

5. Functional Behavioral Assessment Brevard Public Schools
Student: Student #: Date: School: Page ___ of ___
Target behavior #4:
Define target behavior: (What does it look like?)
How often does it occur?
(i.e. 2 x’s a day, 5 x’s per week)
How long does it last?
(i.e. 3-5 minutes, 30 seconds)
Severity of behavior:
Mild: Little risk to property or health/disruption to class 5 minutes or less per hour
Moderate: Property damage or minor injury/disruption to class 5 – 10 minutes per hour
Severe: Profound threat to health or safety/disruption to class 10 minutes or more per hour
Situations when the behavior is most likely to occur:
(i.e. times of day, activity, subject, specific people present)
Situations when the behavior is least likely to occur:
(i.e. times of day, activity, subject, specific people present)
Functional Behavioral Assessment
Brevard Public Schools
Antecedents:
What happens immediately before the target behavior occurs?
Consequences:
What happens immediately after the target behavior occurs?
Function/purpose of behavior:
(Specify/Describe)
Preferred items/materials Preferred activities Preferred people/social situations
Student receives access to:
Student avoids/escapes:
Student receives attention (+/-) from peers
Student receives attention (+/-) from adults
Behavior is self stimulating/entertaining and/or feels good
Behavior relieves discomfort or pain
(Specify/Describe)
Non-preferred tasks/demands Non-preferred activities Non-preferred people/social situations
Revised
FBA/BIP - Comprehensive

6. Behavioral Intervention Plan Brevard Public Schools
Student: Student #: Date: School: Page ___ of ___
Preventative Interventions:
What environmental adjustments will be used to make the student’s problem behavior no longer necessary?
Modifying physical settings or routines
Modifying staff approaches
Clarifying expectations
New processes of monitoring/reporting progress
Behavioral Intervention Plan
Brevard Public Schools
Interventions for Replacement Behaviors:
What behaviors will you teach so that the student no longer needs to engage in the target behavior(s) to get this need met?
Revised
FBA/BIP - Comprehensive

7. Behavioral Intervention Plan Brevard Public Schools
Student: Student #: Date: School: Page ___ of ___
Functional Interventions:
How will the environment change when the student engages in the desired replacement behavior(s)?
How will the environment change when the student engages in the problem behavior?
Student will receive access to preferred items, activities, social situations
Positive attention from others
Free time
Tokens, stickers, special recognition
Student is ignored
Student not permitted access to preferred items, activities, social situations
Behavioral Intervention Plan
Brevard Public Schools
Crisis Management Plan: District approved Crisis Prevention and Intervention (CPI) techniques will be used as warranted to prevent crisis situations from arising, facilitate de-escalation of potentially dangerous behavior, and to ensure safety of self and others.
Monitoring (Who and how will data be collected to assess Response to Intervention?):
Evaluation (Who and when will the Behavioral Intervention Plan be reviewed and/or revised?
Teacher will maintain daily data collection on form attached.
Child Study/IEP Team will review data and modify interventions in this plan: as needed to ensure progress.
(when)
Revised
FBA/BIP - Comprehensive

8. Brevard Public Schools
Page ___ of ___
Data Collection RE: Target Behavior # ____
Data Collection RE: Replacement Behavior
Definition of Replacement Behavior:
Brevard Public Schools

9. Brevard Public Schools
Page ___ of ___
Data Collection RE: Target Behavior # ____
Data Collection RE: Replacement Behavior
Definition of Replacement Behavior:
Brevard Public Schools