Antecedent Behavior Consequences Checklist
ADVERTISEMENT
1Antecedent-Behavior-Consequence Checklist
Student _______________________________________ Class____________________________ School ______________________ Behavior of Concern _____________________________
Date:
Time:
Location:
Antecedent (before behavior)
Behavior
Consequences (after behavior)
Frequency
o
o
o
Given direction/task/activity
Refusing to follow directions
Verbal redirection
1 2 3 4 5 6 7 8 9 10
o
o
o
Asked to wait
Making verbal threats
Physical assist/prompt
11 12 13 14 15 16
o
o
o
New task/activity
Disrupting class _____________
Ignored problem behavior
17 18 19 20 21 22
o
o
o
Difficult task/activity
Crying/whining
Continued demand
23 24 25 26 27 28 29 30 31 32 33 34
o
o
o
Preferred activity interrupted
Screaming/yelling
Used proximity control
35 36 37 38 39 40 41 42 43 44 45 46
o
o
o
Activity/Item denied (told no)
Scratching
Verbal reprimand
47 48 49 50 51 52 53 54 55 56 57 58
o
o
o
Loud, noisy environment
Biting
Removed from activity/location
59 60 61 62 63 64 65 66 67 68 69 70
o
o
o
Given assistance/correction
Spitting
Given another task/activity
71 72 73 74 75 76 77 78 79 80 81 82
o
o
o
Transition between locations/activities
Kicking
Interrupted/block and redirected
83 84 85 86 87 88 89 90 91 92 93 94
o
o
o
Attention given to others
Dropping
Isolated within classroom
95 96 97 98 99 100
o
Presence of specific person
o
Running away/bolting
o
Loss of privileges
o
o
o
Attention not given when wanted
Destroying property
Calming/soothing:
o
o
o
No attention/planned ignored
Hitting Self
Verbal/physical/both
o
o
o
No appropriate activity/ ignored
Hitting Others
Peer remarks/laughter
o
o
o
Other____________________
Verbal refusal
Time-out (duration) ____________
o
o
Other____________________
Other _______________________
Duration: _______<1 min
______ .5-1 hr
Intensity:
Observer_______________________________________________________
_______ 1-5 min
______ 1-2 hr
_____ Low
Notes:
_______ 5-10 min
______ 2-3 hr
_____ Medium
__________________________________________________________________________________________
_______ 10-30 min
______ 3+ hr
_____ High
__________________________________________________________________________________________
Date:
Time:
Location:
Antecedent (before behavior)
Behavior
Consequences (after behavior)
Frequency
o
o
o
Given direction/task/activity
Refusing to follow directions
Verbal redirection
1 2 3 4 5 6 7 8 9 10
o
o
o
Asked to wait
Making verbal threats
Physical assist/prompt
11 12 13 14 15 16
o
o
o
New task/activity
Disrupting class _____________
Ignored problem behavior
17 18 19 20 21 22
o
o
o
Difficult task/activity
Crying/whining
Continued demand
23 24 25 26 27 28 29 30 31 32 33 34
o
o
o
Preferred activity interrupted
Screaming/yelling
Used proximity control
35 36 37 38 39 40 41 42 43 44 45 46
o
o
o
Activity/Item denied (told no)
Scratching
Verbal reprimand
47 48 49 50 51 52 53 54 55 56 57 58
o
o
o
Loud, noisy environment
Biting
Removed from activity/location
59 60 61 62 63 64 65 66 67 68 69 70
o
o
o
Given assistance/correction
Spitting
Given another task/activity
71 72 73 74 75 76 77 78 79 80 81 82
o
o
o
Transition between locations/activities
Kicking
Interrupted/block and redirected
83 84 85 86 87 88 89 90 91 92 93 94
o
o
o
Attention given to others
Dropping
Isolated within classroom
95 96 97 98 99 100
o
o
o
Presence of specific person
Running away/bolting
Loss of privileges
o
o
o
Attention not given when wanted
Destroying property
Calming/soothing:
o
o
o
No attention/planned ignored
Hitting Self
Verbal/physical/both
o
o
o
No appropriate activity/ ignored
Hitting Others
Peer remarks/laughter
o
o
o
Other____________________
Verbal refusal
Time-out (duration) ____________
o
Other____________________
o
Other _______________________
Duration: _______<1 min
______ .5-1 hr
Intensity:
Observer_______________________________________________________
_______ 1-5 min
______ 1-2 hr
_____ Low
Notes:
_______ 5-10 min
______ 2-3 hr
_____ Medium
__________________________________________________________________________________________
_______ 10-30 min
______ 3+ hr
_____ High
__________________________________________________________________________________________
(Emotional Considerations-Required Form –D)
________ of _______
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life