Data Collection Tool For Students With Behavior Problems
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1July 2010
PBIS 2 for School Age
New Hanover County Schools
Data Collection Tool
For Students with Behavior Problems
DIRECTIONS RELATED TO THIS FORM ARE LOCATED ON PBIS 1.
IF UTILIZING PROBLEM SOLVING MODEL PSM 1a, COMPLETE ONLY SECTIONS ON THIS FORM
THAT RECORD ADDITIONAL OR DIFFERENT INFORMATION.
Complete this tool for students referred to the Student Support Team (SST) for behavior problems. Attach this
form to the Request for Intervention Assistance tool.
Name _____________________________
ID# __________________
Date of Birth ____________
School ____________________________
Grade ________________
Completed By ______________________
Date _________________
Attendance: Date of Enrollment ________
Schools Previously Attended
Years Attended
# Days Absent _______
_______________________
_____________
# Days Tardy ________
_______________________
_____________
Retentions: ___Yes ___No If yes, what grade(s)? ______________
Current Grades:
High school only: # credits earned toward graduation__________
Subject
Grade
Subject
Grade
___________________
_____
___________________
_____
___________________
_____
___________________
_____
___________________
_____
___________________
_____
Testing Information: (List all within the last 2 years.)
Test Name
Date(s)
Score(s)
(EOG/EOC’s, writing tests, ___________________
__________________
_________________
9-week assessments,
___________________
__________________
_________________
standardized tests, etc.)
___________________
__________________
_________________
Discipline/Behavioral Information:
If student attended other schools, have Module 3 Discipline files
(attach copy of Dtrack)
been requested ? _____
and received ? _____
# Office Referrals _____
Describe current behavior plan : ___________________________
# In School Suspensions _____
_____________________________________________________
# Out of School Suspensions _____
_____________________________________________________
# Bus Referrals ______
# Bus Suspensions _____
Current Diagnoses:
Current Medications:
Medical ___________________________________
_____________________________
Mental Health ______________________________
_____________________________
Involvement with Other Agencies:
Agency
Contact Person’s
Phone #
Date Release of Information
Name & Title
Signed by Parent
__________________
_____________________
_______________
_______________________
__________________
_____________________
_______________
_______________________
Family Information:
Social/Peer Information:
Other Important Information:
___________________________
___________________________
______________________________
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