Behavior Intervention Plan Form
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ACADIA PARISH SPECIAL EDUCATION DEPARTMENT
BEHAVIOR INTERVENTION PLAN
Student
_______________________School_____________________ Age ____Grade_____ Exceptionality _____________IEP Holder _________________Initial Development Date ____________
Step 1
ID the behavior and its function (FBA)
Number of Referrals _____ Number of Suspensions _____ Number of ISS _____
Date of Incident:
____________
What is the exact behavior?
What was the function (reason) of the behavior?
Refer to Hawthorne Book Teacher’s Guide to Behavior Interventions (Color-Teal and Tan) for BIP goals/objectives and Interventions.
Step 2
Select a replacement/target behavior
(PBIS)
GOAL: What should the student do instead? (Desired behavior)
{Who, Behavior, Criterion, Conditions, Timeframe}
BEHAVIOR OBJECTIVES:
Specific to the behavior
Step 3
Interventions to help develop replacement skills OR a prevention strategy (Ex: Daily readings concerning anger control, seating change, teacher proximity)
Step 4
Complete Reinforcement (RF) survey with student to determine meaningful rewards-list RF able to provide
Step 5
Criteria that student must meet to earn the desired RF (Ex:When student completes 5 days without fighting, he will receive 20 minutes of free time on the computer)
Step 6
Monitoring: Successfulness of BIP will be overseen by: ________________________ Method:______________________________ Frequency:_______________
Ex: By: Teacher
Method:Behavior charting, Jpams discipline referrals, teacher collaboration
Frequency: review weekly
ADDITIONAL MONITORING: Ex: 1). Student, self monitoring chart, daily
2). BIP Team, meet and discuss reviewing data collected, each 6 wks
By:
Method:
Frequency:
By:
Method:
Frequency:
Actions needed if not successful:
Next Meeting Date:
Revisit reinforcers, rewards and interventions
Signatures:
Date: ___________
Revisit Meeting Date/Comments
Student
Parent
Date:
Administrator
Teacher
Date:
Teacher
C.I.
Date:
Other
Counselor
Date:
Other
Other
Date:
Other
Other
Date:
Other
Other
Date:
Revised 8/4/2010 SAR
TEACHER COPY
SPED COPY
PARENT COPY
OTHER: __________________________________
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