Student Name: _________________________________________________________ Resource Teacher: ______________________________________________________

School: __________________________________________________________________ Gen. Ed. Teacher: ________________________________________________________

Grade: __________________________________________________________________ Principal: ________________________________________________________________
Description of Target Behavior (observable, measurable description):

Date: __________________ Time: __________________ Location: ______________________________________ Activity: _______________________________________

Antecedent Behavior
◻ Given direction / task / activity ◻ Not following directions
◻ Asked to wait ◻ Making verbal threats
◻ New task / activity ◻ Disrupting class (describe)
◻ Difficult task / activity ◻ Crying / whining
◻ Preferred activity interrupted ◻ Screaming / yelling
◻ Activity / item denied (told “no”) ◻ Scratching
◻ Loud, noisy environment ◻ Biting
◻ Given assistance / correction ◻ Spitting
◻ Transition between locations ◻ Kicking
◻ Transition between activities ◻ Flopping
◻ Attention given to others ◻ Running away / bolting
◻ Presence of specific person ◻ Destroying / Throwing property
◻ Attention not given ◻ Flipping furniture
◻ No individual attention & left alone ◻ Hitting self
◻ No appropriate activity & left alone ◻ Hitting others
◻ Verbal refusal
Other Other
Consequence Duration of Behavior Notes
◻ Verbal redirection ◻ < 1 min ◻ 30 min - 1 hr
◻ Physical assist / prompt ◻ 1 - 5 mins ◻ 1 - 2 hrs
◻ Ignored problem behavior ◻ 5 - 10 mins ◻ 2 - 3 hrs
◻ Kept demand on ◻ 10 - 30 mins ◻ 3+ hrs
◻ Used proximity control
◻ Verbal reprimand Intensity of Behavior
◻ Removed from activity
◻ Given another task / activity
◻ Interrupted and redirected ◻ mild :
◻ Left alone disruptive but not dangerous
◻ Isolated within class
◻ Loss of privilege ◻ moderate :
◻ Calming / soothing: verbal / physical threats and / or
◻ verbal ◻ physical ◻ both destructive to physical environment
◻ Peer remarks / laughter
◻ Time-out ◻ severe :
poses an immediate physical danger
to self and / or other students
Other

Date: __________________ Time: __________________ Location: ______________________________________ Activity: _______________________________________

Antecedent Behavior
◻ Given direction / task / activity ◻ Not following directions
◻ Asked to wait ◻ Making verbal threats
◻ New task / activity ◻ Disrupting class (describe)
◻ Difficult task / activity ◻ Crying / whining
◻ Preferred activity interrupted ◻ Screaming / yelling
◻ Activity / item denied (told “no”) ◻ Scratching
◻ Loud, noisy environment ◻ Biting
◻ Given assistance / correction ◻ Spitting
◻ Transition between locations ◻ Kicking
◻ Transition between activities ◻ Flopping
◻ Attention given to others ◻ Running away / bolting
◻ Presence of specific person ◻ Destroying / Throwing property
◻ Attention not given ◻ Flipping furniture
◻ No individual attention & left alone ◻ Hitting self
◻ No appropriate activity & left alone ◻ Hitting others
◻ Verbal refusal
Other Other
Consequence Duration of Behavior Notes
◻ Verbal redirection ◻ < 1 min ◻ 30 min - 1 hr
◻ Physical assist / prompt ◻ 1 - 5 mins ◻ 1 - 2 hrs
◻ Ignored problem behavior ◻ 5 - 10 mins ◻ 2 - 3 hrs
◻ Kept demand on ◻ 10 - 30 mins ◻ 3+ hrs
◻ Used proximity control
◻ Verbal reprimand Intensity of Behavior
◻ Removed from activity
◻ Given another task / activity
◻ Interrupted and redirected ◻ mild :
◻ Left alone disruptive but not dangerous
◻ Isolated within class
◻ Loss of privilege ◻ moderate :
◻ Calming / soothing: verbal / physical threats and / or
◻ verbal ◻ physical ◻ both destructive to physical environment
◻ Peer remarks / laughter
◻ Time-out ◻ severe :
poses an immediate physical danger
to self and / or other students
Other

© 2016 Michael Ryan Hunsaker, Ph.D. - ABC Checklist