Behavior Survey

Student:
Hour: _________
Target Behavior #1: Blurting out during lessons
1) About how often in an average class period does student blurt out during inappropriate
times?

2) How distracting is this behavior to you and to the students? (Please circle one and add
any comments)
Not distracting

somewhat distracting

very distracting

3) What, if anything, has been successful in helping the studdent with this behavior in your
class?

Target Behavior #2: Making inappropriate comments to peers

1) About how often does student make inappropriate comments to his peers during your
class?

2) When do these comments usually occur? For example, do they occur during lessons,
unstructured times, at the beginning of class, etc.

3) What seems to trigger the comments?

4) What, if anything, has been successful in helping the student with this behavior in your
class?

Please list any other behaviors you have observed.