Brownsville Independent School District
Student:
D.O.B.:
ID#:
Bilingual:
Grade:
Campus:
Date:
Response to Intervention Process
Positive Behavior Support Plan Referral Checklist
RTI 10
Note: THIS FORM IS USED WHEN CONSIDERING THE NEED FOR A FORMALIZED POSITIVE BEHAVIOR
SUPPORT PLAN (PBSP), REFERRALS FOR BEHAFIORAL DISABILITIES AND/OR LONG-TERM REMOVALS.
DIRECTIONS: Keeping in mind the targeted behavior of concern, describe the situation in which the behavior
occurs:
LOCATION: __________________
TIME: ____________________________
FREQUENCY OF TARGET BEHAVIOR:
PERSON: ___________________________
INSTRUCTIONAL TIME: ____________________________
OTHER FACTORS FOR CONSIDERATION:
IS STUDENT ILL? ______________
PRESCRIPTION MEDICATION? (SPECIFY)_____________________
ACADEMIC PROBLEMS? _______
PROBLEMS AT HOME?________
OTHER FACTORS?__________
DIRECTIONS: PLEASE INDICATE THE STRATEGIES YOU HAVE IMPLEMENTED PRIOR TO MAKING THIS REQUEST AND
DEGREE OF SUCCESS.
STRATEGIES IMPLEMENTED:
RESULTS:
ASSIGNMENT SHEETS
COUNSELOR BEHAVIOR CHART
DISCIPLINE/OFFICE REFERRALS
SUCCESSFUL
SHOWED IMPROVEMENT
UNSUCCESSFUL
SUCCESSFUL
SHOWED IMPROVEMENT
UNSUCCESSFUL
SUCCESSFUL
SHOWED IMPROVEMENT
UNSUCCESSFUL
HOME SCHOOL NOTES
SUCCESSFUL
SHOWED IMPROVEMENT
UNSUCCESSFUL
PARENT CONFERENCE(S)
SUCCESSFUL
SHOWED IMPROVEMENT
UNSUCCESSFUL
PARENT PHONE CONTACTS
SUCCESSFUL
SHOWED IMPROVEMENT
UNSUCCESSFUL
PEER TUTORING
SUCCESSFUL
SHOWED IMPROVEMENT
UNSUCCESSFUL
STUDENT CONFERENCE(S)
SUCCESSFUL
SHOWED IMPROVEMENT
UNSUCCESSFUL
TEAM CONFERENCE(S)
SUCCESSFUL
SHOWED IMPROVEMENT
UNSUCCESSFUL
TUTORING BEFORE/AFTER SCHOOL
SUCCESSFUL
SHOWED IMPROVEMENT
UNSUCCESSFUL
August 2013
Brownsville Independent School District
Student:
D.O.B.:
ID#:
Grade:
Bilingual:
Campus:
Date:
Response to Intervention Process
CLASSROOM BEHAVIOR OBSERVATION DATA
RTI 11
TIME OF OBSERVATION:
ROOM:
DIRECTIONS: COMPLETE THIS FORM ONLY IF A STUDENT REFERRED TO THE RTI CORE TEAM EXHIBITS VERY SERIOUS
BEHAVIOR CONCERNS. CLASSROOM OBSERVATION OF A STUDENT SHOULD BE PERFORMED BY A MEMBER OF THE
BROWNSVILLE ISD RTI CORE TEAM. THIS MEMBER SHOULD BE A NEUTRAL PARTY AND NOT THE STUDENT’S REGULAR
TEACHER. THE PURPOSE OF THIS OBSERVATION IS TO RECORD THE STUDENT’S BEHAVIOR IN AN AREA WHERE HIS/HER
ACHIEVEMENT IS LAGGING BEHIND HIS/HER LEARNING POTENTIAL.
AREAS TO BE OBSERVED INCLUDE: (CHECK ALL APPLICABLE AREAS TO BE OBSERVED):
ATTENTION SKILLS
COMPREHENSION SKILLS
EXPRESSIVE SKILLS
Legend:
Y=Yes
N= No
ABILITY FOR INDEPENDENT WORK
PROBLEM-SOLVING STRATEGIES
OTHER:
N.O.= Not Observed
S= Sometimes
Responds (written/verbal) reasonable length of time
Exhibits attention span for learning
Follows directions
Works independently
Understands classroom activities
Uses problem-solving strategies
Stays on task
Follows classroom rules
Exhibits social interaction skills
Alert and involved
Comprehends written/verbal information
Physical stamina
Additional Observation Information:
How do these behaviors affect educational functioning? Explain.
____________________________________________________
OBSERVER’S Name (Signature)
________________
Date
August 2013
Brownsville Independent School District
Student:
D.O.B.:
ID#:
Bilingual:
Grade:
Campus:
Response to Intervention Process
Functional Behavioral Assessment
Date:
RTI 12
REASONS FOR INITIATING THE FUCTIONAL BEHAVIORAL ASSESSMENT AND POSITIVE BEHAVIOR SUPPORT
PLANNING PROCESS:
The student’s behavior interferes with his/her learning.
The student’s behavior interferes with others learning.
The student has violated student code of conduct and removal to an Alternative Educational Setting or
suspension is being considered or has occurred.
Removal:
More than 10 school days.
10 school days or fewer.
Part of a series of removals totaling more than 10 school days and continues a pattern of behavior.
REVIEW OF PRIOR BEHAVIOR SUPPORT PLANS OR OTHER BEHAVIORAL INTERVENTIONS:
Prior PBSP in effect? _____
*If yes then attach copies
Previous Intervention Implemented
Frequency:
D= Daily
W= Weekly
M=Monthly
N=As Needed
Effectiveness:
Not
Somewhat
Effective
Effective
Very
Effective
Instructional Strategies:
Positive Reinforcement:
Reductive Consequences:
Sources of background information considered for this FBA.
Attach Behavior Checklist
Attach Recent Observation Data
Attach Discipline Records
Attach Information from Other Services Providers
August 2013
Brownsville Independent School District
Student:
ID#:
D.O.B.:
Grade:
Bilingual:
Campus:
Date:
RTI 12 Con’t
Complete Check Form, Circle choices applicable to student
Prioritized Behavior:
Antecedents:
Location:
Classroom
Hall
Library
Other:
Time of Day:
Morning
Afternoon
Lunch
Other:
Observable Behavior:
Behavior:
Consequences:
Behavior
Function:
Comment:
Behavior Ignored:
Yes
No
Avoidance or Escape:
Ignore Directive
Avoid Assignment
Escape Situation/Person
Other:
Person:
Teacher
Students
Support Staff
Other:
Frequency:
1-3 times a day
4-10 times a day
11-15times a day
Other:
Duration:
5 minutes
10 minutes
15 minutes
Other:
Adult Attention:
Reminder
Repeated Request
Meeting/Conference
Reprimand/Warning
Attention:
Peer Attention
Adult Attention
Parent Attention
Other:
Interruption:
Out of Seat
Talking
Throwing
Other:
Intensity:
Mild
Moderate
Moderate-Severe
Severe
Loss of Privilege:
Snack
Computer Time
Class Manager
Other:
Self Control:
Frustration
Express Anger
Vengeance
Other:
Consequence:
Office Referral
Call Parent
Conference Parent/Student
Other:
Parent Contact:
Yes
No
Date:____________
Time Out:
5 minutes
10 minutes
15 minutes
Other:
Sensory/Emotional Reaction:
Fear
Anxiety
Sensory Relief/Stimulation
Other:
*NOTE: Minimum of 1 Prioritized Behavior, no more than 3 Prioritized Behaviors
____________________________
RtI Chairperson
_____________________________
Teacher of Record
_____________________________
Dean
_____________________________
Counselor
August 2013