Date: 10/29/09
Page 1 of 3
►Required for Disciplinary Change of Placement◄
1. TARGET BEHAVIOR (restate IEP goal addressing behavior):
Memo»Behaviors of Concern:
Non Compliance- verbally or passively refusing to follow a directive given by a teacher or school staff, and escaping
Verbal Aggression - verbal threats, insults, antagonizing comments, towards peers/staff
Physical Aggression - hits, kicks, choking towards self and others, destruction of property
Replacement Target Behaviors
Student will engage in socially appropriate behaviors in the school environment. He will be compliant with adult requests, use prosocial skills when interacting with peers/adults, and respect other people's personal space and social boundaries. «
2. PREVENTION ACTIVITIES
Prevention Activities
(state prevention activities in observable terms)
Memo»-shortened or modified assignments - reduced
number of problems as needed
-needs to be reminded to wear glasses before given board or
reading work
-frequent checks for understanding with a review of
directions and expectations
-break multi-step assortments into smaller steps with visual
and verbal cues as needed
-preferential seating - minimal distractions, close to teacher,
close to front of the room
-access to quiet/less stimulating working environment
-redirection to appropriate behavior when Student becomes
agitated
-alternate between preferred and non-preferred tasks
-have P.E. as an afternoon class
-a plan of 20 minutes on and 20 minutes off will be
implemented by agreement of both teacher and Student as
needed
-classroom and/or daily reinforcement system with
expectations and consequences clearly outlined and
individualized
-prior notice when there are changes to his daily schedule
such as substitutes, assemblies etc
-structured and predictable routines
-opportunities for helping (started P.E. aide on Oct 5th)
-allowed to eat while actively working
-allow age appropriate "fidget"«"
How Often ?
Daily
3: WHAT WILL BE TAUGHT?
What Will Be Taught?
(What other behaviors or skills will be taught so that the
student can meet his or her needs in an acceptable manner?)
Memo»-Social skills instruction during teachable moments
and in role playing and contrived situations
Who Is
Progress Monitoring 
Responsible?
Method
Special Education
Data logs, data charts 
Teacher,
Paraprofessional and
school staff

How Often ?
Daily
Who Is
Responsible?
Special education
teacher, general
Progress Monitoring
Method
Daily communication 
log, data sheets and
January 2007
Form 650
Copy to the confidential folder, each service provider, and the parent/adult student.
-conflict resolutions and stress reduction strategies taught in
small group setting, role playing and contrived situations
-teach appropriate communication skills - such as how to
ask for clarification/assistance, request a break, move to
more quiet setting to work, advocate for his own needs
- learn to identify triggers for undesired behaviors and how
to respond in a more appropriate way
-teach self-control and self-management skills in the areas
of anger management and coping skills
-teach replacement behavior for when he is
frustrated/overloaded to put his head on the desk when he
feels the need to run
- when he is overloaded, he needs to be directed to go to the
office for a break«
4: RESPONSE TO TARGET BEHAVIOR
Response Management
How will adults respond when the problem behavior occurs
so that their response does not
(1) reinforce the student’s inappropriate behavior
or (2) cause the adult greater stress?
Memo»Reinforce Appropriate Behaviors
-high rates of positive responses and acknowledgement
from teacher and peers for appropriate behaviors
- earn rewards and incentives as well as time to work on
preferred activities
- daily notes home to reinforce appropriate choices and
behaviors
Response to Inappropriate Behaviors
- redirect Student to the task
- planned ignoring, neutral body language, quiet voice,
minimal talking
- offer him help, clarification, or modifications for the
assignment
- offer alternative location to work on the assignment or
task
- provide Student with a reminder of daily reinforcement
system and opportunity to earn rewards and/or time for
preferred activities
- provide a neutral prompt to the calming strategies, he can
use to help de-escalate
-replace sharp writing instruments with crayons
education teacher,
administrators
grades

How Often ?
Per incident
Who Is
Responsible?
School
administrators,
teachers, and
paraprofessionals
Progress Monitoring
Method
Incident report, daily 
communication log
In the event of severe aggressive behaviors towards peers or
self or adults, Student will have alteration to his
environment. For example, being escorted to the office,
room clear as needed and deflection strategies.
A call to parents by administrators, nurse or designee’ and
written in the communication log when medication is given.
If Student uses physical aggression toward an adult or a
peer, the staff will use responses for safety only (student
and other individuals)
January 2007
Form 650
Copy to the confidential folder, each service provider, and the parent/adult student.
The first response will be to try and use non-verbal and
verbal de-escalation strategies. (i.e. say “head down” and
place a coin (as a reward) on desk, giving verbal affirmation
as he complies.)
If a MANDT hold is required, parent will be contacted as
soon as possible.
If Student continues to use aggression and become unsafe to
himself or others, then Student will be restrained using a
MANDT approved restraint. Starting with a body hug, if
this is not enough to support and manage Student’s
behavior he may be placed in a one arm standing restraint.
If he cannot be safely managed in a one arm standing
restraint, he will be restrained using a two arm standing
restraint. This restraint will only be used for the purpose of
protecting Student, or another peer or adult to keep Student
or others safe during the crisis.
Invite Student to eat or give a self-soothing activity
suggestion during a hold to facilitate deescalation.
A restraint will only last until Student begins to de-escalate
and is no longer a danger to himself or others and will not
exceed the time limit of 3 minutes. At 3 minutes, the hold
will be evaluated to determine if law enforcement should be
contacted.«
January 2007
Form 650
Copy to the confidential folder, each service provider, and the parent/adult student.