Section 504 Student Services Plan (Page 3 of 4) in pdf

Section 504 Student Services Plan Page 3

Form 12, page 3 of 4

Section 504 Behavior Intervention Plan

[This form should be considered when the §504 Committee determines that the Student’s behavior

interferes with his ability to learn or the ability of other students to learn.]

Student Name:

Student ID:

School:

Date of Plan:

Please list below each behavior, reinforcement, consequence and person responsible for administering the

reinforcement or consequence. Appropriate intervention is based on assessment data, discipline history,

social history, parent reports and other data.

Behaviors targeted for intervention:

Please select or add the appropriate behavior interventions for this student. Please use the notes and

information page to explain choices and to ensure compliance.

Clearly defined limits

Journal of daily behaviors

Proximity seating

Frequent reminder of rules

Reinforce appropriate behavior

Cooling off period

Reduce distracting stimuli

Supervised unstructured time

Peer intervention

Consistent routine

Behavioral contract (attach)

Other

Communicate behavioral progress or status with parents through (check one):

Weekly tracking form

Notes home

Phone call

Daily tracking form

Parent conference

When a communication other than a tracking form is chosen, describe the frequency of required contact

here (when particular behaviors occur, every two weeks, etc).

When a targeted behavior occurs, the following occurs:

Targeted Behavior

Reward for desired

Consequence for

Person responsible for

behavior

undesired behavior

Reward or consequence

Section 504 Student Services Plan Page 3