Student: Date of Birth: OSIS: Date: December 8, 2011

Consent for Functional Behavior Assessment and Behavior Intervention Plan

Dear Ms., We are writing to obtain your consent to conduct a Functional Behavior Assessment (FBA) and Behavior Intervention Plan (BIP) for [name]. An FBA is generally recommended when a student exhibits behaviors that interfere with his learning or the learning of others. We believe that [name] could benefit from an FBA. An FBA is generally conducted within the school, during the school day. It consists of observations of the student in class and in after-school activities, review of his educational records, discussions with his teachers, and discussions with parents about the students behavior at home and in different settings. The purpose of the FBA is to develop a Behavior Intervention Plan (BIP) which will help teachers at KIPP to address [name]s classroom behaviors that interfere with his ability to learn. The Plan will be developed with your input. If you have any questions please contact Mr. Craig Varsa, School Psychologist, at 646-257-9876 or cvarsa@kippnyc.org. If you consent to this assessment please sign and date below:

_____________________ Parent/guardian signature

_____________________ Date

Please return this form with your child at your earliest convenience.