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Date/Time Antecedent Behavior Consequence (what Attention received at Hypothesized Function

& Trial (What happened before) (√ all observed) happened after behavior) prior to incident
Date:  Asked to work  Refusal  Offered Choice  Alone  Gain Attention
 Item/activity restricted  Verbal Disruption  Reprimand  Adult attention  Gain Item
Time:  Attention restricted  Physical Disruption  Discussion  Peer attention  Gain Sensory
 Transition from  Physical Aggression  Prompt: ______  Whole group  Escape Attention
Trial #: ___________________to  Self Injury  Removed item instruction  Escape Demand
___________________.  Elopement Ignored  Small group  Escape Sensory
   Gave attention to others instruction
 Time-out
  Said: ________________

Date:  Asked to work  Refusal  Offered Choice  Alone  Gain Attention


 Item/activity restricted  Verbal Disruption  Reprimand  Adult attention  Gain Item
Time:  Attention restricted  Physical Disruption  Discussion  Peer attention  Gain Sensory
 Transition from  Physical Aggression  Prompt: ______  Whole group  Escape Attention
Trial #: ___________________to  Self Injury  Removed item instruction  Escape Demand
___________________.  Elopement Ignored  Small group  Escape Sensory
   Gave attention to others instruction
 Time-out
  Said: ________________

Date:  Asked to work  Refusal  Offered Choice  Alone  Gain Attention


 Item/activity restricted  Verbal Disruption  Reprimand  Adult attention  Gain Item
Time:  Attention restricted  Physical Disruption  Discussion  Peer attention  Gain Sensory
 Transition from  Physical Aggression  Prompt: ______  Whole group  Escape Attention
Trial #: ___________________to  Self Injury  Removed item instruction  Escape Demand
___________________.  Elopement Ignored  Small group  Escape Sensory
   Gave attention to others instruction
 Time-out
  Said: ________________

Adapted on 2/24/2014 by Amy, Jessica, and Seth