BEHAVIOR OBSERVATION FORM (EDCHS804)
INSTRUCTIONS
This is a tool that is used by staff to gather information about achild=s behavior/activities during a typical day. Parents should be encouraged to use the PARENT OBSERVATION FORM (ECDHS112) to observe their child at the center.
Ideally, the Teacher, Partnership Mentor, Classroom Assistant, Nutrition Assistant, Special Needs Assistant, or Disabilities/Prevention/Mental Health Manager will observe a child for 20-30 minutes for 3 days. This is a concentrated observation. The Mental Health Consultant, the Disabilities/Prevention/Mental Health Manager, or another professional (ex. neurologist, psychologist, etc.) may need to review these to get more information about the child=s typical day at Head Start.
Enter child=s name. (example: Clay W.)
Enter day of the week and the date of the observation. (Ex: Tues, Sept 26)
Enter observer=s name. (Ex. BAWanosik)
Enter the time of the observation (ex. 2:15-2:40)
Record the following, in note format, to the best of your ability:
a. Approximate length of Time from Antecedent to Consequence (ex. 2:18-2:20)
b. Antecedent - (ex. Clay=s friend was playing blocks with someone else. At breakfast Clay and his friend talked about building a tower together during IE)
c. Behavior - (ex. kicked over block tower)
d. Consequence - (ex. Clay=s friend said to Clay, AI don=t like you anymore, you=re not my friend!@ CA redirected Clay to read a story with her.)
This information may help Head Start staff, the Parent, and other professionals determine areas of need for the child. A Child Intervention Plan would be the appropriate tool to transfer this knowledge along with the behavior assessment data into a plan of action.
Keep original copy in child=s file. REV 2/11
BEHAVIOR ASSESSMENT FOR (ECDH804A & ECDH804B)
INSTRUCTIONS
After completing the BEHAVIOR OBSERVATION FORM (EDCHS804), please complete this BEHAVIOR ASSESSMENT FORM. The data gathered from this behavior assessment and the BEHAVIOR OBSERVATION FORM (EDCHS804) and the BEHAVIOR BASELINE TRACKING CHART (ECDHS804C) will be used when creating a CHILD INTERVENTION PLAN (ECDH805).
1. Enter child=s name.
2. Enter behavior problem to be addressed.
3. Write your name at Aassessment completed by.@
4. Fill in the date of the assessment.
5. Complete the RELATIONSHIP OF THE HISTORY section.
6. Complete the SOCIAL INFLUENCES Section by checking Y(yes) or N(no) for each question.
7. Complete the SOCIAL REINFORCEMENT Section by checking Y(yes) or N(no) for each question.
8. Complete the NON-SOCIAL OR AUTOMATIC REINFORCEMENT Section by checking Y(yes) or N(no) for each question.
9. Complete the SCORING SUMMARY. This will indicate the type of behavior being demonstrated.
Place the original in the child=s file and send a photocopy to the MH Manager.
7/03
BEHAVIOR BASELINE TRACKING CHART(ECDHS 804C)
Staff use this form BEFORE a Child Intervention Plan (ECDHS805) has been completed. This chart is used to track behavior identified on the Behavior Observation Form (ECDHS804) and the Behavior Assessment Form (ECDHS804 A & B).
1. Enter the child=s ID number. The chart will be placed in a spot in the room where staff can easily track behaviors throughout the day, therefore, you must not put the child=s name on it.
2. Enter the target behavior being tracked.
3. In the first box, note the dates of the week in which the observations are occurring. The behavior should be tracked for a minimum of 2-3 days, preferably a week or more. As soon as the staff feel they need help with a behavior, start tracking, and continue until help arrives and a plan is put into place.
4. The behavior is charted by making a tally mark when the child displays the target behavior.
This Behavior Baseline Chart will be used along with other assessment tools to help create an intervention plan.
Keep the original document in the child=s file. The Mental Health Consultant and Mental Health Manager need a copy for their files.
7/03