This form has been adjusted to collect duration, abc, and intensity data. The information will be used to complete a scatterplot and frequency data form, so it is imperative that every problem behavior is noted to ensure accurate data.

NAME: / TEACHER: / TARGET BEHAVIOR: see behavior column below
DATE / ACTIVITY / What was happening before or while the behavior occurred? (Check all that apply) / BEHAVIOR / Intensity
See attached rating scales for this. / What happened after the behavior? (Check all that apply)
Start time:
Stop Time:
Staff Initials / q  Bathroom
q  Hallway
q  Independent
q  Large group lecture
q  Cooperative group
q  Seatwork-Indep.
q  Math
q  Reading
q  Soc. St/Science
q  Music
q  Library
q  Writing
q  Lunch
q  Playground
q  Other ______/ q  Asked to work / Given a direction/Task Demand
q  Walking in the hallway
q  Sitting in a group activity
q  Transition/Between activities
q  Class was noisy
q  Change in routine
q  Written work demand
q  A peer approached him to interact
q  Got excited (e.g., being reinforced for right answer)
q  Reprimanded
q  Other______/  Throwing obj/paper
 Noises, screams, cries  Profanity
 Flop/sit/crawl on floor  Disrespect-talk back, stays instead of moves
 Runs away
 Mumbling above level 3 voice
 Acts like animal
 Aggression—kicks, hits
 Impulsivity-attempt to pull alarm
 Verbal threats
 Other______/ Compliance and productivity
1 2 3
Aggression
0 1 2 3 4
Voice level
0 1 2 3 4 5 / q  Verbally redirected
q  Corrected (e.g., told “no”)
q  Physically redirected
q  Other child yelled or reprimanded him—interacted in some way
q  Removed from setting
q  Parent called
q  Work demand adjusted
q  Work demand withdrawn
q  Redirected to ask for a break or attention
q  Redirected to another activity or action
q  Sent to break area/cool down
q  Other______
q  Comments
Prompts: Indicate how many prompts:
Gestural ___
Proximity ___
Visual/Model ___
Verbal ___
Start time:
Stop Time:
Staff Initials / q  Bathroom
q  Hallway
q  Independent
q  Large group lecture
q  Cooperative group
q  Seatwork-Indep.
q  Math
q  Reading
q  Soc. St/Science
q  Music
q  Library
q  Writing
q  Lunch
q  Playground
q  Other ______/ q  Asked to work / Given a direction/Task Demand
q  Walking in the hallway
q  Sitting in a group activity
q  Transition/Between activities
q  Class was noisy
q  Change in routine
q  Written work demand
q  A peer approached him to interact
q  Got excited (e.g., being reinforced for right answer)
q  Reprimanded
q  Other______/  Throwing obj/paper
 Noises, screams, cries  Profanity
 Flop/sit/crawl on floor  Disrespect-talk back, stays instead of moves
 Runs away
 Mumbling above level 3 voice
 Acts like animal
 Aggression—kicks, hits
 Impulsivity-attempt to pull alarm
q  Verbal Threats
q  Other / Compliance and productivity
1 2 3
Aggression
0 1 2 3 4
Voice level
0 1 2 3 4 5 / q  Verbally redirected
q  Corrected (e.g., told “no”)
q  Physically redirected
q  Other child yelled or reprimanded him—interacted in some way
q  Removed from setting
q  Parent called
q  Work demand adjusted
q  Work demand withdrawn
q  Redirected to ask for a break or attention
q  Redirected to another activity or action
q  Sent to break area/cool down
q  Other______
Comments
Prompts: Indicate how many prompts:
Gestural ___
Proximity ___
Visual/Model ___
Verbal ___
Time/Activity / Hitting head with open palm—1-3 consecutive hits is one incident. / Scratching others / Pinching others-includes breasts
730 / Freq. / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11
Antecedent
Consequence
Intensity
745 / Freq.
Antecedent
Consequence
Intensity
800 / Freq.
Antecedent
Consequence
Intensity
815 / Freq.
Antecedent
Consequence
Intensity
830 / Freq.
Antecedent
Consequence
Intensity
845 / Freq.
Antecedent
Consequence
Intensity
900 / Freq.
Antecedent
Consequence
Intensity
Antecedent:
B-bathroom D-Task demand T-transition Consequence: G-Gesture I-Ignore H-held P-Proximity R-Redirection V-Verbal response
Intensity: 0-no mark 1- whelp or redness visible after 3 minutes 3-broken skin/bleeding requires cleaning and bandage 4-requires dr. or emergency care
Time/Activity / Hitting head with open palm—1-3 consecutive hits is one incident. / Scratching others / Pinching others-includes breasts
915 / Freq. / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11
Antecedent
Consequence
Intensity
930 / Freq.
Antecedent
Consequence
Intensity
945 / Freq.
Antecedent
Consequence
Intensity
1000 / Freq.
Antecedent
Consequence
Intensity
1015 / Freq.
Antecedent
Consequence
Intensity
1030 / Freq.
Antecedent
Consequence
Intensity
1045 / Freq.
Antecedent
Consequence
Intensity
Antecedent:
B-bathroom D-Task demand T-transition Consequence: G-Gesture I-Ignore H-held P-Proximity R-Redirection V-Verbal response
Intensity: 0-no mark 1- whelp or redness visible after 3 minutes 3-broken skin/bleeding requires cleaning and bandage 4-requires dr. or emergency care