Department of Education

Required Forms for

Functional Behavioral Assessment and Behavioral Intervention Planning

This Packet Contains:

Required Forms:

• Functional Behavioral Assessments (FBA) Form (April 2017)

• Behavioral Intervention Plan (BIP) Form (April 2017)

• Considerations for Positive Behavior Supports Form (December 2013)

Writable versions of the aboveforms may befound on the NYCDOE Intranet Special Populations Special Education Office Special Education Resources Understanding Behavioral Supports Resources Functional Behavioral Assessments (FBAs) and Behavioral Intervention Plans (Bf Ps)

Cover Page FBABIP Req ui r ed Forms and Directions

Functional Behavioral Assessment

Date Developed: Cli ck here t o enter a date .

Student Name: Stu den t Name            NYCID #: NYCID # Age: Age Date of Birth: Cli ck here to ent er a d at e.

School: School Teacher/Class: Teacher/ Class Grade: Grade

1. ldentifv school staff who participated in the FBA team process

Print Name	Title	Signature
Print Name	Tit le
Print	Title
Prin t Name	Tit le
Prin t Name	Title
Prin t Nam e	Title
Prin t Na m e	Titl e

• Identify and define the Targeted Problem Behavior(s)

8 NYCRR § 200.l{r)

Identify ONE Targeted Problem Behavior or ONE Response Class of behaviors and define the behavior(s) in observable/measurable, and concrete terms. If there is more than one Targeted Problem Behavior or one Response Class of behaviors, please complete a separate FBA.

□The ONE Targeted Problem Behavior* is: ONE Target Pr ob lem Beh avior

*E.g., hitting peers or screaming or throwing objects, etc. List one single behavior.

OR,

□The ONE Response Class** of behaviors is: ONE Resp onse Class consisting of the following behaviors: Ident if y Behaviors

**Response class is a category of behaviors that is followed by a list of the specific behaviors which occur under similar circumstances or antecedents with the same outcome or function. They usually happen in rapid sequence. (Examples include aggressive behavior consisting of hitting, kicking or pulling hair; tantrums consisting of laying on floor, screaming , flailing arm s, and kicking legs.)

• List of direct and indirect data sources used to  identify and support functional hypothesis  8 NYCRR § 200 . 22(a)(2)

3a. Indirect Data

Check all that apply and attach. The sections in bold must be checked and submitted into SESIS.

• Student interviews (information from the student)
  • Parent interviews (including relevant history and current status)
  • Staff interviews (including teachers, paraprofessionals, related service providers, and

possibly other relevant staff such as cafeteria, bus, custodial, office staff)

• Information from the IEP Present Levels of Performance
  • Assessment of Student Preferences

D Surveys or questionnaires specific to behavior(s)

D Student records review (including current school status)

D Summary of the results of Psychological/Psychiatric Evaluations

(must check and submit if student recommended and/or receiving counseling)

• Medical Information

D Testing data

D Attendance data

D Disciplinary records (e.g. OORS report, SOHO report)

D Other information provided by the parent. Specify: Ot her informat ion

3b. Direct Data

Direct data are gathered from direct observation across multiple settings, by more than one member of the team identified above. The most relevant and appropriate documentation – which includes Antecedent-Behavior-Consequence (ABC} Charts, frequency (how often a behavior occurs), duration (the length of time the behavior lasts}, intensity (how severe the behavior is), and/or latency (how long it takes for a behavior to begin after a specific verbal demand or event has occurred) data measures across activities, settings, peo ple, and times of day – must be checked, attached and submitted into SESIS.

0 ABC Charts

• Frequency Charts
  • Duration Charts

D Intensity Scales

D Latency Documentation

D Other – Specify: Other in fo rmation

• Global/broad influences related to Targeted Problem Behavior(s) (“Setting Events”) 8 NYCRR §§ 200.l (r) and 200.22(a)(3)

Using indirect and direct data sources, summarize the global/broad influencing factors (including

cognitive, social, sensory, affective factors) that relate to the Targeted Problem Behavior. Influencing factors can include the student’s skills, health/medical, daily routines, relationships, or recent or ongoing events in the student’s life, etc. Indicate and describe all that apply.

Influencing factors (setting events) that increase the likelihood of Targeted  Problem Behavior(s)	Provide specific details of the influencing factors
□Impact of recent/ongoing events □Family issues/home environment □History of the behavior □Skill/performance deficits □Physical/health/medical issues □Negative thinking habits □Other:	Cli ck here to enter text .

• Description of antecedent(s)

8 NYCRR §§  200.l  (r ) and 200.22(a)(3)

What occurs before and triggers the Targeted Problem Behavior?

Situations/events/activities/people that seem to trigger the Targeted Problem Behavior:

□Demand of or request to student

□Difficult task

□Non-preferred activity

□Non-pr eferred social interaction

□Transition from preferred to non-preferred activity

□Changes in schedul e or routine

□ Environmental conditions

□Other: Other information

Describe items checked above in det ail:

Cl i ck here to enter text.

Times of the school day when the Targeted Problem Behavior  most often occurs: Cli ck h ere to ent er text.

• Description of conseguence(s)

8 NYCRR §§ 200.l (r) and 200.2 2(a)(3)

Describe the consequence{s) of the Targeted Problem Behavior{s). What happens immediately after the Targeted Problem Behavior{s) that seems to encourage it? What consequences increase the likelihood of the Targeted Problem Behavior{s) occurring again? Include adult/peer responses and what happens in the immediate environment (e.g., get s attention from peers, avoids non-preferred task, etc.).

Click h ere to enter text.

7.    Function of the Behavior(s) 8 NYCRR § 200 . 22(a)( 3}

Check the applicable box(e s ) below and provide details.

The student GETS/GAINS:

□Teacher/Adult Attention: Cli ck here to enter t ext.

□Peer Attention: Cli ck here to enter t ext.

□Sensory/Stimulation: Click here to enter text.

□Tangible/Preferred Activity: Cli ck here to enter text.

□Oth er: Cl i ck here to enter text.

The student AVOIDS/ESCAPES:

□Teacher/Adult Attention: Click here to ent er t ext .

□Peer Attention: Cli ck here to enter text.

□Sensory/Stimulation: Clic k here to enter text .

□Non-Preferred Activity/Task: Cli ck here to ente r text.

□A Difficult Task: Cli ck here to enter t ext.

D Other: Cli ck here to ent er t ext.

8.    Skill/performance deficits related to Targeted Problem Behavior(s) 8 NYCRR § 200 .l ( r) and 200.22(a)(2}

List skill and/or performance deficits related to Targeted Problem Behavior(s). A skill-based de ficit is

when a student does not know how to perform a certain task. A performance-based deficit exists when a student knows how perform the skill but does not perform it at the desired level.

Cli ck h ere to ent er text.

• Baseline data

8 NYCRR § 200. 22(a)(3}

Using the contextual information above, provide a narrative data description with regard to the frequency, duration, intensity and latency (if applicable) of the Targeted Problem Behavior(s) across activities, settings, people, and times of day. Use the same measures for the Behavioral Intervention Plan (BIP} and Progress Monitoring.

Cli ck h ere to enter text.

Frequency (how often a behavior occurs): Fr equency (average number per day and/or week, etc.)

Duration (how long a behavior lasts): Durat ion (average length of time of behavior)

Intensity (how severe the behavior is): In t ensity (average intensity of behavior)

(Use these Intensity Levels or define a scale below: 1- impacts only the student, 2- impacts neighboring peers, 3- impacts entire class, 4- impacts neighboring classes, 5- impacts the whole school/violent behavior)                     Intensity Scale

1 Cli ck here to ente r text.

2 Cli ck here to ent er text.

3 Cli ck here to enter text.

4 Cli ck here to ent er t ext .

5 Cli ck here to ent er text .

Latency (how long it takes for a behavior to begin after a specific verbal demand or event has occurred) (if applicable): Lat ency (average time after demand or event)

1. Diagram the functional hypothesis

8 NYCRR § 20 0.l (r)

Setting Events (Conditions that increase likelihood of behavior(s))	Antecedent (What occurs before?)	Target Problem Behavior(s) (Observable/Measurable)	Maintaining Consequence/ Function
Clic k her e to en t er	Click here to enter	Click her e to enter t ext.	Consequence/Outcome
t ext .	text.		What happens after the
			Targeted Problem Behavior?
			Clic k her e to ent er text .
			Function
			What does the student
			Get: Cli ck h ere to ent er t ext .
			and/or Avoid: Cli ck here to ent er text.

1. Statement of functional hypothesis

Narrative that describes the function of the targeted problem behavior(s) (functional hypothesis) based on the data. Functional statement reads:

For example: When David is presented with academic work in large or small group settings requiring writing, multiple work sheets, or work that he perceives to be difficult (describe what occurs just before the Problem Behavior(s) – the ANTECEDENT) David (student’s name) will engage in disruptive behavior (response class) consisting of the following behaviors: mumble derogatory comments about the teacher, refuse to complete his work, destroy his assignment sheet, and/or push/kick his desk or chair over. Any or all of these behaviors may occur. (description of PROBLEM BEHAVIOR(S)) within

seconds (amount of time after antecedent occurs – LATENCY) at an approximate rate/duration of fl_ times per week for approximately 5 minutes each time (data collection baseline of FREQUENCY/ DURATION) and then the teacher calls on someone else and drops the request (describe what happens after the behavior(s) that maintains/reinforces it – the CONSEQUENCE) in order to avoid the non­ preferred task and negative peer attention (what the student gets or  avoids by doing the behavior(s)  –  the FUNCTION of the behavior(s)). This behavior is most likely to occur when David is asked to do something in which he has a skill deficit (e.g., writing, multi-step problems, etc. ) or he has expressed negative self-statements earlier in the day  (e.g.,”I  hate (expletive)  writing, I can’t  do this…”  ) or previously embarrassed in front of peers. (state possible SETTING EVENTS).

When describe what occurs just before the Problem Behav ior(s) – the ANTECEDENT  student’s name will descr ipt ion of PROBLEM BEHA VIOR{S) within am ount of t ime after antecedent occur s-LATENCY at an approximate rate/duration of data collection base li ne of FREQUENCY/ DURATION and then

descr i b e what happens after the behavior(s) that maint ain s/ rei nforces it- the  CONSEQUENCE in  order to what the student gets or avo ids by do ing th e behav ior(s ) – the FUNCTION of the behavior(s) . This behavior is most likely to occur when state possible SETTING EVE NTS.

1. Behavioral supports and interventions previously tried

8 NYCRR § 200.22{a)(2)

Describe any classroom, small group, or individualized behavioral supports and/or interventions previously attempted for the student and the results of these interventions. What interventions were implemented? What data was used to determine effectiveness? Over what period of time?

Cli ck h ere to enter text.

1. Behavioral supports and interventions currently in place

8 NYCRR § 200 . 22 {a}(3)

Describe classroom, small group, or individualized behavioral supports and/or interventions currently in place for student (e.g. individual counseling, check–in check-out, etc.). What interventions are currently being implemented? What data is being used to determine effectiveness? Over what period of time?

Cli ck here to ent er text.

1. Describe/list student’s interests and possible reinforcers

8 NYCRR § 20 0.22{a}(3)

Refer to Assessment of Student Preferences, IEP, and Staff/Parent/Student Interviews as appropriate. Reinforcement is the process by which a behavior is followed by a given consequence that increases the probability that the behavior will occur again. There are different types of reinforcers (e.g. attention, activities, tangibles, or sensory experiences).

Answer the questions below, and submit evidence of the student’s interests, preferences, reinforcers, and/or motivators into SESIS.

1. What are the student’s interests or prefer ences? Cli ck here to enter text.

• What does the student find reinforcing or motivating?

Cli ck here to enter text.

• What is not reinforcing or motivating for this student? Cli ck here to enter text.

1. Replacement behavior(s) that serve the same function and strategies for teaching new behavior(s)

8 NYCRR § 2 00 . 22 (a }(3)

There are three essential characteristics of replacement behaviors:

1. They serve the same function as the problem behavior.
2. They are easier to do that the problem behavior.
3. They are socially acceptable.

Identify the replacement behavior(s) that serves the same function as the Targeted Problem Behavior(s): Cli ck here to enter text.

Provide recommendations for teaching alternative skills or behaviors that will replace the Targeted Problem Behavior(s): Cli ck h ere to ente r text.

Behavioral Intervention Plan

Date Developed: Click here to ente r a date.

Student Name: Student Nam e            NYCID #: NYCID # Age: Age Date of Birth: Click here to ent er a date.

School: School Teacher/Class: Teacher/ Cl ass Grade: Grade

1. Identify school staff who participated in BIP development:

Print Name	Title	Signature
IPrint Name	Titl e
Pr int Name	Tit le
Print Nam e	Titl e
Print Name	Tit le
Print Nam e	Tit le

• Identify and define the Target Problem Behavior(s) (copy this exactly from the FBA):

8 NYCRR § 200.22(b }{4}

Identify ONE Targeted Problem Behavior or ONE Response Class of behaviors and define the behavior(s) in observable/ measurable, and concrete terms. If there is more than one Targeted Problem Behavior or one Response Class of behaviors , please complete a separate FBA.

□The ONE Targeted Problem Behavior* is: ONE Target Pro b lem Behavior

*E.g., hitting peers or screaming or throwing objects, etc. List one single behavior.

OR,

□The ONE Response Class** of behaviors is: ONE Respon se Class consisting of the following behaviors: Identify Behaviors

**Response class is a category of behaviors that is followed by a list of t h e specific behavior s which occur under similar circumstances or antecedents with the same outcome or function. They usually happen in rapid sequence. (Examples include aggressive behavior consisting of hitting, kicking or pulling hair; tantrums consisting of laying on floor, screaming, fl ailin g arms, and kicking legs.)

• Baseline data (copy this exactly from FBA):

8 NYCRR § 200.22(b)(4)(i}

In clude fr eq u e ncy, duration , intensit y and latency (if applicable) of th e targeted problem behavior(s). Copy this exactly from the FBA.

Click here to enter text.

Frequency (how often a behavior occurs}: Frequency (average number per day and/or week, etc.)

Duration (how long a behavior lasts): Durat ion (average length of time of behavior)

Intensity (how severe the behavior is}: Int ensit y (average int ensit y of behavior)

{Use these Intensity Levels or define a scale below: 1- impacts only the student, 2- impacts neighboring peers, 3- impacts entire class, 4- impacts neighboring classes, 5- impacts the whole school/violent behavior)                     Intensity Scale

1 Click h ere t o enter text.

2 Click here to ent er text.

3 Click here to ent er text .

4 Clic k here to ent er text.

S Click here to enter text.

Latency (how long it takes for a behavior to begin after a specific verbal demand or event has occurred} (if applicable): Lat ency (average time after demand or eve nt)

• . Diagram the functional hypothesis (copy this exactly from FBA):

8 NYCRR § 2 00.l (r}

Setting Events (Conditions that incre ase the likeliho od of the problem beh avior)	Antecedent (What occurs b efo re? )	Target Problem Behavior(s} (Observable/ M easurabl e)	Maintaining Consequence/ Function
Cli ck he re to	Cli ck here to enter	Cli ck here to ent er text.	Consequence/Outcome
enter text.	text.		(What happens after?):
			Click here to ent er t ext .
			Function What does the student Get: Clic k here to enter
			text.
			and/or Avoid: Cli ck h ere
			to enter text.

• Statement of functional hypothesis (copy this exactly from FBA):

Narrative that describes the function of the targeted problem behavior(s) (functional hypothesis) based on the data. Functional statement reads:

For example: When David is presented with academic work in large or small group settings requiring writing, multiple work sheets, or work that he perceives to be difficult (describe what occurs just before the Problem Behavior(s) – the ANTECEDENT) David (student’s name) will engage in disruptive behavior (response class) consisting of the following behaviors: mumble derogatory comments about the teacher, refuse to complete his work, destroy his assignment sheet, and/or push/kick his desk or chair over. Any or all of these behaviors may occur. (description of PROBLEM BEHAVIOR{S)) wit hin

seconds (amount of time after antecedent occurs – LATENCY} at an approximate rate/duration of 2.

times per week for approximately 5 minutes each time (data collection baseline of FREQUENCYI DURATION) and then the teacher calls on someone else and drops the request (describe what happens after the behavior(s) that maintains/reinforces it – the CONSEQUENCE} in order to avoid the non­

preferred task and negative peer attention (what  the student gets or avoids by doing the  behavior(s)  – the FUNCTION of the behavior(s)). This behavior is most likely to occur when David is asked to do something in which he has a skill deficit (e.g., writing, multi–step problems, etc. ) or he has expressed negative self–st atements earlier in  the  day (e.g.,”I  hate (expletive) writing, I can‘ t  do this...“)  or previously embarrassed in front of peers. (state possible SETTING EVE NTS).“

When descr ibe what occurs just before the Prob lem Behavior(s) – the ANTECEDENT student’s name will de scr iption of PROBLEM BEHAVIOR(S) within amount of t ime after antecedent occurs-LATENCYat an approximate rate/duration of data collection base line of FREQUENCY/ DURATION and then

descri be what happens after the behavior(s) that maint ains/ rei nfo rces i t- t h e CONSEQUENCE in  order to wh at the st u dent gets or avo ids by doing the behavior(s) – the FU NCTION of the behavior(s ). This behavior is most likely to occur when state possib le SETTING EVE NTS.

• Global/broad influences related to Targeted Problem Behavior(s} (“Setting Events”} (copy this exactly from FBA}:

8 NYCRR §§ 200.l (r ) and 200.22(a)(3)

Using indirect and direct data sources, summarize the global/broad influencing factors (including cognitive, social, sensory, affective factors) that relate to the Targeted Problem Behavior(s ). Influencing factors can include the student’s skills, health/medical, daily routines, relationships, or recent or ongoing events in the student’s life, etc. Indicate and describe all that apply.

Influencing factors (setting events) that increase the likelihood of Targeted Problem Behavior(s)	Provide specific details of the influencing factors
□Impact  of recent/ongoing events □Family issues/home environment □History of the behavior □Skill/performance deficits □Physical/health/medical issues □Negative thinking habits D Other: Click here to enter text.	Cli ck here to enter text.

• Replacement behavior(s} that serve the  same function and strategies  for teaching new behavior(s}  8 NYCRR § 200 . 22 (a)(3)

There are three essential characteristics of replacement behaviors:

1. They serve the same function as the problem behavior.
   1. They are easier to do that the problem behavior.
   1. They are socially accept able.

Identify the replacement behavior(s) that serve the same function as the Targeted Problem Behavior(s).

Cli ck here to ent er text.

What is the desired behavior/long-term goal for the student (academic skills, social skills, organizational skills?)

Cli ck h ere to enter text.

• Intervention Strategies:

8 NYCRR §§ 200.22(b)(4)(ii) and 200.l(mmm)

“What, where, when, and how” must be developed based on the functional analysis within the FBA. Include strategies that will:

•         alter the setting events and antecedents to prevent the Targeted Problem Be havior(s) ;

• alter the consequences that currently maintain the Targeted Problem Behavior(s); and
• be used to teach alternative and replacement behaviors that serve the same function as the Targeted Problem Behavior(s) while building skills that will make the Targeted Problem Behavior(s) no longer necessary.

8 a. Setting Event Strategies:

How will you remove or prevent setting events? Cli ck here to ent er text.

How will you reduce the effects of setting events if they cannot be removed? Cli ck here to enter text.

8 b. Antecedent Strategies:

How will you change the environment to reduce antecedent triggers for problem behavior(s)? Cli ck here to ent er text.

How will you remind/prompt student to use alternative/replacement behaviors? Cli ck here to enter text.

8 c. Behavior Teaching Strategies:

Describe how you will teach the short-term alternative/replacement behavior? Cl i ck here to enter text.

8 d. Consequence Strategies:

Response after new behavior(s) occur (increase reinforcer):

Cli ck here to ent er text.

Response after problem behavior(s) occur (redirection, de-escalation, reduce reinforcer): Cli ck here to enter text.

• Progress  Monitoring:

8 NYCRR §§ 200 .22(b)(S}, 200.22(b)(4)(iii}

Provide a schedule by which the effectiveness of the interventions/strategies will be measured.

Please note: The result s of the progress monitoring must be documented and report ed to the student’s parents and to the IEP team or CPSE and must be considered in any determination to revise a student’s behavioral intervention plan or IEP.

Progre ss monitoring data must include the same measures that were used for baseline data, including frequency, duration and intensity of the targeted problem behavior(s). It mu st also include data

measu res of the alternative/replacement behavior(s).

Progress Monitoring Schedule must include:

• Specific behavior(s) being monitored (target ed problem behavior(s) and alternative/replacement behavior(s))
• Intervals at which data will be collected
• Who is responsible for data collection
• Tools/data collection methods that will be used

Attachment: Progress Monitoring Review Meeting

1. Document the results of progress monitoring. Progress monitoring must be reported to the student’s parent and IEP team. This form and all data must be faxed into SESIS.

Dat e of Review Meeting: Cli ck here to enter a date.

Staff who participated in Progress Monitoring Review Meeting:

Print Name	Title                                                Signature
Print Name	Tit le
Pri nt Name	Tit le
Pr int Na me	Title
Print Name	Title                                    I                                         I
1 Print Na me	Title

• Data on Targeted Problem Behavior(s)

Describe Targeted Problem Behavior(s): Cli ck here to enter text.
Baseline Data of	Data on Targeted Problem	Data Analysis:	Person(s) Responsible (e.g.,
Targeted Problem	Behavior(s) after	Has the Targeted	collecting data, implementing
Behavior(s):	implementation of BIP for	Problem Behavior	BIP, analyzing data,
Copy frequency,	the specified interval:	decreased?	scheduling review meetings,
duration , and	Update data on Frequency,	(Circle Yes or No)	etc.):
intensity directly from	Duration, and Intensity at
FBA.	every review meeting.
Frequency Cli ck here	Frequency Cli ck here to	Frequency Y/N Duration                    Y/N Intensity       Y/N	Cli ck here to enter text.
to enter text.	enter text .
Duration Click here	Duration Cli ck here to
to enter text.	ent er t ext .
Intensity Click here to	Intensity Cli ck here to
ent er t ext .	e nter text.
	Attach copies of data
	forms and submit into
	SESIS.

• Data on Alternative/Replacement Behavior(s)

Describe the Alternative/ Replacement Behavior(s): Cli ck here to enter text.
Data on Alternative/Replacement Behavior(s) after implementation of BIP for the specified interval: Choose and report on one or more of frequency, duration, or intensity below, as a ppropria te.	Data Analysis: Has the Alternative/ Replacement Behavior increased? (Circle Yes or No as appropriate)	Person(s) Responsible (e.g., collecting data, implementing BIP, analyzing data, scheduling review meetings, etc.):
Frequency Cli ck here to enter text. Duration Click here to enter t ext. Intensity Click here to ent er text. Attach copies of data forms and submit into SESIS.	Frequency     Y/N Duration        Y/N Intensity        Y/N	Click here to enter text.

• Continue plan? (Circle) Y / N

Modify plan?   (Circle)    Y / N

Rational  e: Clic k here to enter text.

Rationale: Click here to  enter t ext.

If “yes” to modify plan, the team as identified in this BIP must meet to modify the plan and send the updat e d plan to the parent and upload to SESIS.

Identify how the results of Progress Monitoring will be shared with the stude nt ‘ s par ent: Cli ck here to ent er text.

Considerations of a Student’s Need for Positive Behavior Supports, FBA, or a BIP CSE/CPSE Initial and Review Meetings

To be completed by the CPSE/CSE

Studen t :                      Date  of Birth:

NYCID:

PARTl: DETERMINATION OF NEED FOR AN FBA

Date of CPSE/CSE meeting:

1. Does t his stud ent displ ay behavior that imp edes hi s or her learnin g or th at of oth ers? Ye s□ No □

If yes, describe:

• Have schoo l-w ide support s or classro om int erventions been consistently implemented and failed to addresst he student’ s behavior adequat ely?

Ye s□  No O

If yes, describe.

• Does t h e student ‘ s behavior place t he stud ent or others at ri sk of phy sical or emotional harm or inju ry? Ye s□ No □

If yes, d escrib e:

• Is t h e CPSE/CSE considering more restri cti ve programs or placements as a resul t of t he st ud ent’ s behavi or?

Ye s□  No □

• Has thi s st udent been suspended or subj ect t o a di sci plin ary removal fo r more than 10 days in the current schoo l year for behavior that was determined to be a m anif est ation of th e st ud ent’ s

disability?

Ye s□  No D

If the response to any of the questions 1-4 above is “yes”, the CPSE/CSE must discuss and determine whether a functional  behavioral  assessment  (FBA) should be conducted.  If the answer to question 5 is “ye s”, an FBA must be conducted.

• Has an FBA for such behavio r ever been con duct ed?

Ye s□  No O          If “y es”, doesthe FBA need to be updated? Yes O No 0

If an FBA has never been conduct ed for t his st udent, does the CPSE/ CSE re comm end that an FBA be conduct ed?

Ye s□  No □

If no,  explain why:

Part 1 completed by:

S gi  na tur  e : ————————————————————————————————— ­

Date:

PART 2: BEHAVIOR INTERVENTION PLAN

Date of meeting:

If an FBA is conducted or updated, the CPSE/CSE must review and discuss the results of the FBA and determine whether the student needs a behavioral intervention plan (BIP) and/or other interventions/supports, including positive behavioral interventions and supports recommended in the student’s individualized education program (IEP).

lfthestudent was suspended or subject  to  a  disciplinary  removal  in  the  current  school year and the behavior was determined to be a manifestation of the student’s disability, a BIP must be developed and implemented or an existing BIP must be updated.

• Do es t he stud ent need a BIP? Ye s D       No 0

If yes, pl ease describe the specific behavior(s) that will be addr essed in the BIP. If no, explain why:

• Will th e st udent’ s IEP o r BIP in clude the use of a ” tim eout room” *? Ye s D No □

If ” yes”, what is t he m aximum amount of tim e the st ud ent should spend in the time out room (per incident )? Please note that thi s ti me limit must be documented in the stud ent’ s IEP.

* Use of a timeout room may only be done in accordance with Regulations of the Commissioner of Education {8 NYCRR 2O0.ZZ(c)). Schools must submit their policies and procedures to DSWDELL for approval before they may use

a timeout room. Use of a timeout room is not a teacher removal and should not be confused with removal of a student to a SAVE room.

• If the student has an existing BIP, does the plan need to be revised based upon review of progress monitoring data to address behavior that resulted in the disciplinary action in question or for any

other reason?

Ye s □  No □

Part 2 completed by:

Signature——————————————————————————– ­

Date: