PINELLAS COUNTY SCHOOLS
ESE TIER 3 PROBLEM SOLVING WORKSHEET
Academic Concern
Functional Behavior Assessment
Behavior Improvement Plan
Student:
School:
Teacher/Case Mgr:
Date of Original
Plan:
Plan Revisions:
(None)
Vision Screening: Date:
Hearing Screening:
Date:
Grade:
BD:
ID:
(None)
STEP I. PROBLEM IDENTIFICATION: What is the problem? (What is the discrepancy between what is expected and what is
occurring?)
List up to 3 behaviors of concern (academic or behavioral):
Select no more than 1 behavior and, when academics are a concern, 1 academic skill to target stating in observable and measurable terms:
Academic:
Behavior:
List school and class wide Interventions in which the student participated (Tier 1):
List targeted small group interventions in which the student participated (Tier 2); attach graph showing comparisons between student and
others in small group:
State discrepancy and/or attach graphs showing comparisons between target student performance, peers, and expected performance (graph
required for behavior):
Academic:
Behavior:
PCS Form 2-3078 Page 1 of 5 (Rev. 9/13)
Review Date 9/14
Category Y
STEP II. Why is the problem occurring? Summarize the relevant data collected through Review of records, Interviews,
Observations, or Tests
_______________________________________________________________________________________________________
I.
Environment Domain: (Include room arrangement, class/school rules, management plan, expectations, class reinforcement and other relevant factors
in the school environment)
Questions to be answered:
Findings:
_______________________________________________________________________________________________________
2. Curriculum Domain: (Include at least: what is taught, instructional materials, expected outcomes, opportunities for review and practice of skills, implicit
vs explicit presentation of information)
Questions to be answered:
Findings:
_______________________________________________________________________________________________________
3. Instruction Domain: (Include at least: instructional placement, decision making, type of instruction, pace, monitoring of student understanding.)
Questions to be answered:
Findings:
4. Learner Domain: (Include at least: strengths, interests & challenges, academic performance levels, social behaviors (least likely to occur, most
likely to occur, health issues)
Questions to be answered:
Findings:
___________________________________________________________________________________________________________________________
PCS Form 2-3078 Page 2 of 5 (Rev. 9/13)
Review Date 9/14
Category Y
List hypotheses and supporting data:



For academic and/or behavior concerns: Select and state the most valid and alterable hypothesis/hypotheses:
For behavior concerns only: Identify the most likely need, i.e. function, that the behavior meets for the student:
STEP III. What are we going to do about the problem?
Replacement Behavior (What do we want the student to do in place of the problem behavior):
Academic:
Behavior (For behavior concerns, replacement behavior must also address the needs of the student, i.e., function of behavior) :
Academic Goal: In
weeks, when
occurs,
(student) will
Behavior Goal: In
weeks, when
occurs,
(student) will
weeks, when
occurs,
2nd Goal (optional for behavior): In
(student) will
Intervention Plan:
What is the Intervention?
Who is responsible?
Where will it happen?
When and how often?
Start Date
Academic:
Behavior:
Implementation Integrity:
Resources (people and materials) needed to support this intervention?
PCS Form 2-3078 Page 3 of 5 (Rev. 9/13)
Review Date 9/14
Category Y
Observation of intervention implementation and of the student response to the intervention to be completed by
and
(Observer 2) during the week of
.
(Observer 1) during the week of
Progress Monitoring Plan:
What will be used to progress monitor?
Who is responsible?
Where will it happen?
When and how often?
Start Date
Academic:
Behavior:
Participating Team Member Signatures:
Administrator
_________________________________
Parent
____________________________________
FBA/Problem Solving
Facilitator
_________________________________
Teacher
____________________________________
Intervention Coordinator
_________________________________
Diagnostician
____________________________________
School Psychologist
_________________________________
Social Worker
____________________________________
Behavior Specialist
_________________________________
____________________________________
Notes:
Date of next meeting to review data and the response to interventions:
PCS Form 2-3078 Page 4 of 5 (Rev. 9/13)
Review Date 9/14
Category Y
STEP IV. Evaluation of the response to the intervention: Is it working?
A.
B.
Meeting Date:
A. Is data graphed and sufficient to make decisions?
Yes:
Next Step - Continue to item B
No:
Next Step - Implement intervention and continue collecting and charting progress monitoring data
B. Based on the progress monitoring data, is the student making progress toward the goal?
Goal met or exceeded:
Next Step: Continue and/or fade intervention
Yes, but goal not reached:
Next Step: Continue or modify intervention until goal is met.
No improvement or got worse:
Next Step: Recycle through the problem-solving process (Intervention Process Guide)
C. Based on the progress monitoring data, is the discrepancy between the student and peers decreasing?
Yes
Next Step: Continue intervention until discrepancy is no longer present
No, discrepancy increasing or
unchanged
Next Step: Recycle through the problem-solving process (Intervention Process Guide)
Next Meeting Date:
PCS Form 2-3078 Page 5 of 5 (Rev. 9/13)
Review Date 9/14
Category Y