The School Board of Broward County, Florida
Intervention Record—Behavior
Student:
School:
Teacher(s):
DOB:
Grade:
Review of Tier 1 Interventions: School-Wide Positive Behavior Plan
CHAMPs
Other
Behavior(s) Targeted for Intervention:
Destruction of property
Failure to follow adult directions
Incomplete assignments
Off task
Physical aggression
Running away/out of assigned area
Throwing objects
Verbal aggression
Yelling/screaming
Other:
Expectations Taught:
Handle property appropriately
Follow directions after one reminder
Complete academic tasks
Remain on task
Keep hands and feet to oneself
Remain in assigned area
Handle objects appropriately
Speak in non-aggressive terms
Speak in a normal tone of voice
Baseline data for each target behavior identified. (e.g. # of referrals for target behavior or # of incomplete
assignments per week, etc.)
Strategies Used in the General Education Classroom to Address Student’s Targeted Behaviors:
breaking tasks into steps
contracting
allowing breaks
point system
positive reinforcement
problem solving
direct teaching
time out
token economy
verbal instruction
role play
modeling
differentiated instruction
other:
Expectations taught by:
(Name/Title)
(Date)
Parent contacted to discuss area(s) of concern for this student by:
(Name/Title)
(Date)
Tier 1 Intervention(s) were not successful:
Student has accessed the school-wide positive behavior plan (i.e. earned Broward Bucks, etc.)
Yes
No If no, explain:
Percent of students in this class achieving behavioral benchmarks: >74.
Request assignment of case manager to assist with interventions.
Case manager assigned:
Name (print)
Position
Administrator checklist:
Student had access to the school-wide positive behavior plan.
The behavior plan has been effective with approximately 75% to 80% of the class.
Administrator Signature
Date
Revised: 2/1/11 psycserv
This form is based on the Intervention Summary created by members of The School District of Osceola County, Florida.
Student:
Tier 1 should be effective for approximately 75% to 80% of the class level. If not, CPS
and/or administration need to review and make necessary adjustments to the school-wide
discipline plan and/or its implementation.
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Student:
Tier 2: Implementation of Targeted Group Academic Intervention(s)
Meeting Date
Information from Records, Interviews, and Observations [What did review of records, communications
with other involved persons, and direct observations add to understanding the problem?]
What do the data suggest is the likely cause of the problem? (Problem Hypothesis)
Collect and graph the data that show the performance of the student compared to other students for the
target behavior (related to the cause of the problem above) before intervention (baseline). Use the same
appropriate and objective measurement tool for each data point in the graph (e.g. number of assignments
handed in; percent of time off task; number referrals for fighting, etc.)
Tier 2 Evidence-Based Intervention(s) to be Implemented in Addition to Tier 1 [Refer to LEAPS, RIDE,
Intervention Central website, etc.]
Skill(s) to target
Who will implement the intervention? (i.e. interventionist)
Where will the intervention take place?
Frequency and length of sessions
Materials needed
Progress monitoring tool [if possible use same tool as for baseline data above]
Person(s) responsible for progress monitoring
How often and for how long will progress be monitored?
Numerical goal (e.g. reduce referrals for defiance to zero, increae work completion to 75%)
Notification of Professional Support Services (letter) provided to parent. Date
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Student:
Tier 2: Intervention Support Plan
Person responsible for supporting interventionist
Identify what/how supports will be provided
Review Outcome of Tier 2 Intervention(s)
Collaborative Problem Solving Team (CPST) Meeting Date:
Provide a graphic representation of Tier 2 effectiveness by comparing baseline data to current data
and the Tier 2 goal (Graphed data attached)
Tier 2 intervention(s) were successful: fade to Tier 1 and continue graphic progress monitoring.
Tier 2 intervention(s) were not successful; check one of the following:
Interventions not implemented as designed (content, frequency, etc.).
Next Step: Implement Tier 2 intervention as designed.*
Consider alternative Tier 2 intervention.*
Refer to CPST, conduct FBA, and consider possible Tier 3 intervention.
Parent Conference to review graphic representation of student progress toward the Tier 2 goal and to
discuss recommended future action. Date:
*Note: If considering an alternative or modified Tier 2 intervention or refined implementation, attach
additional Tier 2 pages. Also consider the need for Psychosocial Evaluation and/or FBA.
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Student:
Tier 3: Implementation of Intensive/Individualized Academic Intervention(s)
FBA has been completed—Copy Attached
Date of FBA
CPST Meeting Date
Tier 3 Intervention:
Positive Behavior Intervention Plan (PBIP) is attached.
Specific skill(s) targeted by plan:
Who will implement the intervention? (i.e. interventionist)
Where will the intervention take place?
Materials needed:
Progress monitoring tool to be used:
Person(s) responsible for progress monitoring:
How often and for how long will progress be monitored?
Numerical goal (reduce referrals for defiance to zero, increase work completion to 75%)
Tier 3: Intervention Support Plan
Person responsible for supporting interventionist
Identify what/how supports will be provided
Review Outcome of Tier 3 Intervention(s)
Collaborative Problem Solving Team (CPST) Meeting Date:
Provide a graphic representation of Tier 3 effectiveness by comparing baseline data to current data
and the Tier 3 goal (Graphed data attached)
Tier 3 intervention(s) were successful:
Fade back to Tier 2 and continue graphic progress monitoring, or
Fade back to Tier 1 and continue graphic progress monitoring.
Tier 3 intervention(s) were not successful; check one of the following:
Interventions not implemented as designed (content, frequency, etc.).
Next Step: Implement Tier 3 intervention as designed*.
Intervention was implemented with fidelity, but was not successful.
Next Step: Continue/Modify* Tier 3 intervention(s) and refer back to CPST for further
action.
Parent Conference to review graphic representation of student progress toward the Tier 3 goal and to
discuss recommended future action. Date:
*Note: If considering either a modified Tier 3 intervention or a refined implementation, attach additional
Tier 3 pages.
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