Tier II Intervention Form

Student’s Name: ______Date:

Grade:Teacher’s Name:

School:Date of ODR(if any):

Reason forReferral:______

______

______

Target Behavior:______

(Inappropriate behavior, defined behaviorally)

ReplacementBehavior: ______

(What is expected of the student?)

Baseline Data:

(Average of occurrence of problem behavior over the last 3 days)

Occurred ______Times a ☐day ☐ hour

Intervention (Preventive Strategies)- If possible, give number of times or dates.

(Strategies used to correct behavior prior to filling out this form)

Prevention Procedures Documented:____ Praise/recognition of appropriate behavior

____ Clear, concise directions ____ Review rules & expectations/ specifically define limits

____ Frequent reminders/prompts____ Preferential seating

____ Teacher/staff proximity____ Provide highly structured setting

____ Redirect/ speak to student about concerns privately____ Communicate regularly with parents

____ Provide cooling off period/safe place in room____ Provide datesof communication with parents:

______;______;______;______;______

___other (Explain) ______

Date referral is submitted to SWPBIS Team: ______

Referring Teacher’s Signature:______

SWPBIS Team Member’s Signature:______

I have verified that the above Tier I strategies have been implemented.

Administrator Signature:______

Possible Interventions- Choose from the list which strategies you will use to correct behavior.

Modifications to Environment:

☐Seat student away from instigating peers

☐Eliminate distracting items in the classroom

☐Post all classroom rules and daily schedules in prominent locations

☐Create separate or designated work areas

☐Minimize unstructured time

☐Create quiet areas

☐ Provide time alone or time to regroup after a negative event

☐Schedule preferred activities into daily routines

☐Allow flexible seating positions (e.g., stand, sit on knees)

☐Transition supports/provide the appropriate amount of supervision. This communicates that staff are aware of students’ behaviors

☐Proximity Control (the teacher uses proximity control by physically positioning himself in close proximity of the student)

☐The teacher will provide the student with a more highly structured routine, schedule, and classroom environment

☐Change class schedule.

☐Other: ______

Proactive Strategies: The Teacher will:

☐Use Precision Request:

☐Decide which behaviors to ignore

☐When decisions are needed, give two choices or options

☐Academic work is at the appropriate level.

☐Pace instruction.

☐Systematically teach social skills, including anger management, conflict

☐Discuss strategies that the student may use to calm him or herself when they feel their anger escalating.

☐Other: ______

Proactive Strategies to avoid triggers:

☐ Avoid repetitive tasks

☐Avoid power struggles

☐ Avoid long periods of desk work

☐Avoid negative language, such as: no or stop

☐Avoid talking about the student’s problem behavior in their presence

☐Avoid reprimands

☐Other: ______

Teaching Desired Behavior: Method of Teaching Desired Behavior and by Whom:

  • Direct InstructionBy______
  • Anger Management- By______
  • Role PlayingBy______
  • Behavior ContractBy______
  • Decision Making LessonBy______
  • Social SkillsBy______
  • Providing CuesBy______
  • ModelingBy______
  • Stress ManagementBy______
  • Use of MentorBy______
  • Other______

By______

Frequency of Intervention: (Duration of plan)

  • One week
  • Two weeks
  • Other ______

Method of Progress Monitoring:

  • Direct Observation
  • Daily Behavior Sheet
  • Weekly Behavior Sheet
  • Charting/graphing
  • Self-monitoring
  • Other______

Intervention is conducted by:

______

Teacher’s Signature:Date:

______

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