Mehlville Early Childhood
Positive Behavior Support Reporting Form
Child’s Name: ______________________________ Age: _______ Date: _________ Time: _______ IEP Yes/No
Referring Staff Member: ___________________________ Classroom Teacher: _____________________________
Building: ____________________________
Instructional Time Lost: _______________________
Description of Behavior: (to be completed only when there is physical aggression)
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Complete a PBS Reporting Form for each incident. There should be 15+ minutes between episodes to determine a new incident.
Main Issue of Concern (B):
(Make note of event order by numbering the sequence as it occurs.)
___ Physical Aggression
___ Property Destruction
___ Self-abuse/Stimulation
___ Escape
Location:
___ Structured Classroom Activity
___ Unstructured Classroom Activity
___ Gym
___ Hallway
___ Playground
___ Bus
___ Room Other Than Own
___ Nurse
___ Drop off/Pick up
___ Other: ___________________
Trigger for behavior (A):
___ Adult request/Redirection
___ Unstructured Play
___ Peer Provoked
___ Difficult Task
___ Adult Not in Close Proximity
___ No Peer Attention
___ Adult Attention
___ Transition: ______________
___ Other: ________________
___ Unsure
___ Inappropriate Language
___ Tantrum
___ Other: __________________________________
Activity:
_________________________
________________________
(i.e., bathroom, music, transition,
circle, centers, snack, clean up)
Others Involved:
___ Peer
___ Teacher
___ Paraprofessional
___ Specialist
___ Bus Driver
___ Substitute
___ Administration
___ Nurse
___ Others: ________________
Response to Behavior (C):
(Check all that apply & circle the most effective C)
___ Adult Verbal Attention
___ Loss of Privilege
___ Adult Physical Attention
___ Choice Given
___ Adult Eye Contact
___ Practice of Skill
___ Adult Ignored Behavior
___ Sensory Strategy
___ Peer Verbal Attention
___ Redirection
___ Peer Physical Attention
___ Caregiver Contact
___ Peer Ignored Behavior
___ Other: _______________
___ Removal from Activity
___ Conference with Student
___ Re-Teaching of Rule/Routine
___ Communication Supports
___ Access to Desired Object
___ Staff Terminated the Request
Possible Function:
___ Obtain Adult Attention
___ Obtain Peer(s) Attention
___ Obtain Object
___ Avoid Adult
___ Avoid Peer(s)
___ Avoid Task Demand
___ Obtain Sensory Input
___ Avoid Sensory Input
___ Unsure
Additional Comments:
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Mehlville Early Childhood
Positive Behavior Support Reporting Form
When to Complete a PBS Reporting Form:
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Always when it is a safety issue (intentional aggression to self or others & running away)
Behaviors NOT age appropriate
Chronic challenging behavior (i.e., crying/whining)
Teacher’s instructional time lost due to one specific child’s behaviors
Main Issue of Concern (B) Definitions:
Physical Aggression= Hitting, kicking, biting, slapping, pinching, scratching, or otherwise attempting to make forceful contact with another
person.
Property Destruction= To ruin the structure or condition of the environment (i.e., dumping, breaking, knocking over, ripping décor off the
wall, etc.)
Inappropriate Language= Improper and/or irrelevant verbalizations including cursing, unkind words, and “being mean”.
Tantrum= Excessive refusal possibly including a combination of the following behaviors: screaming, crying, escaping, physical aggression,
and property destruction.
Escape= Leaving the immediate area/boundary or avoidance of task (i.e., running from classroom/playground, flopping, hiding under table,
or turning into noodle body)
Self Abuse= Hitting, kicking, biting, slapping, pinching, scratching, or otherwise attempting to make forceful contact with oneself
Self Stimulation= Repetitive form of behavior to produce sensory stimulation for the person which upsets the learning environment.
Other= Any chronic, safety, or otherwise disruptive challenging behavior that is not listed above.
Additional Comments:
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