Behavior Information Collection Sheet

Student name: BEATRIZ DOS SANTOS Grade: 9 Date: 02/17/2023 Completed by:

Student Strengths/Interests

Behavior(s) of Concern Frequency Duration Intensity

minutes/hours minutes/hours 1 to 5
daily/weekly days/weeks low high

Other Information:

Observation of the Behavior:

Behavior 1 Setting Events Antecedents Consequences Function
Please X the items Please X the items that Please X what happens Please identify what
that increase the set off/immediately after the behavior occurs student gains or avoids
likelihood of the trigger the behavior
behavior

☐ Outside stressor ☐ Given difficult task ☐ Ignored Obtain/Gain:

☐ Tired ☐ Given ☐ Discussion (adult ☐ Peer attention
☐ Bad mood non-preferred student) ☐ Adult attention
☐ Transitions task ☐ Redirection ☐ Access to
☐ Large group ☐ Removal of ☐ preferred activities
☐ Small group preferred Reprimand/warnin ☐ Access to
☐ One on one activity/object g ☐ Time-out preferred object
Ignored (attention ☐ Sent to office ☐ Other:
☐ Independent work
removed)
☐ Group instruction ☐ Sent home
☐ Teased Avoid/Escape:
☐ Class activity ☐ Loss of
☐ Reprimanded ☐Difficult
☐ Morning privileges/incentives
☐ Time out activity/task
☐ Afternoon ☐ Call to parents
☐ Loud noises ☐ Other: ☐Non-preferred
☐ Change in routine ☐ Negative social activity/task
☐ In classroom interaction ☐Peer/adult social
☐ Unstructured ☐ Other: contact
time (e.g., ☐ Correction/
recess) Reprimand
☐ Other: ☐Changes in
routine ☐Other:

Behavior 1 Preventative Reinforcement Reduction-Oriented Please indicate

Interventions Strategies Strategies Consequence other
Please X the items Please X the items that apply Strategies Please X the interventions tried
provided to student items that apply
that apply
 ☐ Preferential ☐ Verbal praise ☐ Ignore behavior
Seating ☐ Visual ☐ Social praise (i.e. ☐ Redirection
schedule high five) ☐ Conference
☐ Frequent breaks ☐ Free time ☐ Remove privileges
☐ Reduce difficulty ☐ Preferred activity ☐ Time out
of work ☐Time with a certain ☐ Reprimand
person
☐ Point
system/token
economy

Observation of the Behavior:

Behavior 2 Setting Events Antecedents Consequences Function
Please X the items Please X the items that Please X what happens Please identify what
that increase the set off/immediately after the behavior occurs student gains or avoids
likelihood of the trigger the behavior
behavior

☐ Outside stressor ☐ Given difficult task ☐ Ignored Obtain/Gain:

☐ Tired ☐ Given ☐ Discussion (adult ☐ Peer attention
☐ Bad mood non-preferred student) ☐ Adult attention
☐ Transitions task ☐ Redirection ☐ Access to
☐ Large group ☐ Removal of ☐ preferred activities
☐ Small group preferred Reprimand/warnin ☐ Access to
☐ One on one activity/object g ☐ Time-out preferred object
Ignored (attention ☐ Sent to office ☐ Other:
☐ Independent work
removed)
☐ Group instruction ☐ Sent home
☐ Teased Avoid/Escape:
☐ Class activity ☐ Loss of
☐ Reprimanded ☐Difficult
☐ Morning privileges/incentives
☐ Time out activity/task
☐ Afternoon ☐ Call to parents
☐ Loud noises ☐Non-preferred
☐ Change in routine ☐ Other:
☐ Negative social activity/task
☐ In classroom interaction ☐Peer/adult social
☐ Unstructured ☐ Other: contact
time (e.g., ☐ Correction/
recess) Reprimand
☐ Other: ☐Changes in
routine ☐Other:

Behavior 2 Preventative Reinforcement Reduction-Oriented Please indicate

Interventions Strategies Strategies Consequence other
Please X the items Please X the items that apply Strategies Please X the interventions tried
provided to student items that apply
that apply

☐ Preferential ☐ Verbal praise ☐ Ignore behavior

Seating ☐ Visual ☐ Social praise (i.e. ☐ Redirection
schedule high five) ☐ Conference
☐ Frequent breaks ☐ Free time ☐ Remove privileges
☐ Reduce difficulty ☐ Preferred activity ☐ Time out
of work ☐Time with a certain ☐ Reprimand
person
☐ Point
system/token
economy

Observation of the Behavior:

 Behavior 3 Setting Events Antecedents Consequences Function
Please X the items Please X the items that Please X what happens Please identify what
that increase the set off/immediately after the behavior occurs student gains or avoids
likelihood of the trigger the behavior
behavior

☐ Outside stressor ☐ Given difficult task ☐ Ignored Obtain/Gain:

☐ Tired ☐ Given ☐ Discussion (adult ☐ Peer attention
☐ Bad mood non-preferred student) ☐ Adult attention
☐ Transitions task ☐ Redirection ☐ Access to
☐ Large group ☐ Removal of ☐ preferred activities
☐ Small group preferred Reprimand/warnin ☐ Access to
☐ One on one activity/object g ☐ Time-out preferred object
Ignored (attention ☐ Sent to office ☐ Other:
☐ Independent work
removed)
☐ Group instruction ☐ Sent home
☐ Teased Avoid/Escape:
☐ Class activity ☐ Loss of
☐ Reprimanded ☐Difficult
☐ Morning privileges/incentives
☐ Time out activity/task
☐ Afternoon ☐ Call to parents
☐ Loud noises ☐ Other: ☐Non-preferred
☐ Change in routine ☐ Negative social activity/task
☐ In classroom interaction ☐Peer/adult social
☐ Unstructured ☐ Other: contact
time (e.g., ☐ Correction/
recess) Reprimand
☐ Other: ☐Changes in
routine ☐Other:

Behavior 3 Preventative Reinforcement Reduction-Oriented Please indicate

Interventions Strategies Strategies Consequence other
Please X the items Please X the items that apply Strategies Please X the interventions tried
provided to student items that apply
that apply

☐ Preferential ☐ Verbal praise ☐ Ignore behavior

Seating ☐ Visual ☐ Social praise (i.e. ☐ Redirection
schedule high five) ☐ Conference
☐ Frequent breaks ☐ Free time ☐ Remove privileges
☐ Reduce difficulty ☐ Preferred activity ☐ Time out
of work ☐Time with a certain ☐ Reprimand
person
☐ Point
system/token
economy

Additional notes/comments: