PINELLAS COUNTY SCHOOLS
ESE TIER 3 PROBLEM SOLVING WORKSHEET
Academic Concern Functional Behavior Assessment
Behavior Improvement Plan
Student: / School: / Grade: / BD: / ID:Teacher/Case Mgr: / Date of Original Plan: / Plan Revisions:
Hearing Screening: Date: / (None)PassFailFollow-up / Vision Screening: Date: / (None)PassFailFollow-up
STEP I. PROBLEM IDENTIFICATION: What is the problem? (What is the discrepancy between what is expected and what is occurring?)
List up to 3 behaviors of concern (academic or behavioral):
Select no more than 1 behavior and, when academics are a concern, 1 academic skill to target stating in observable and measurable terms:
Academic:
Behavior:
List school and class wide Interventions in which the student participated (Tier 1):
List targeted small group interventions in which the student participated (Tier 2); attach graph showing comparisons between student and others in small group:
State discrepancy and/or attach graphs showing comparisons between target student performance, peers, and expected performance (graph required for behavior):
Academic:
Behavior:
STEP II. Why is the problem occurring? Summarize the relevant data collected through Review of records, Interviews, Observations, or Tests
______
- Environment Domain: (Include room arrangement, class/school rules, management plan, expectations, class reinforcement and other relevant factors in the school environment)
Questions to be answered:
Findings:
______
2. Curriculum Domain: (Include at least: what is taught, instructional materials, expected outcomes, opportunities for review and practice of skills, implicit vs explicit presentation of information)
Questions to be answered:
Findings:
______
3. Instruction Domain: (Include at least: instructional placement, decision making, type of instruction, pace, monitoring of student understanding.)
Questions to be answered:
Findings:
4. Learner Domain: (Include at least: strengths, interests & challenges, academic performance levels, social behaviors (least likely to occur, most
likely to occur, health issues)
Questions to be answered:
Findings:
______
List hypotheses and supporting data:
For academic and/or behavior concerns: Select and state the most valid and alterable hypothesis/hypotheses:
For behavior concerns only: Identify the most likely need, i.e. function, that the behavior meets for the student:
STEP III. What are we going to do about the problem?ReplacementBehavior (Whatdo we want the student to do in place of the problem behavior):
Academic:
Behavior (For behavior concerns, replacement behavior must also address the needs of the student, i.e., function of behavior):
Academic Goal: In weeks, when occurs, (student) will
Behavior Goal: In weeks, when occurs, (student) will
2nd Goal (optional for behavior): In weeks, when occurs, (student) will
Intervention Plan:What is the Intervention? / Who is responsible? / Where will it happen? / When and how often? / Start Date
Academic:
Behavior:
Implementation Integrity:
Resources (people and materials) needed to support this intervention?
Observation of intervention implementation and of the student response to the intervention to be completed by (Observer 1) during the week of and (Observer 2) during the week of.
Progress Monitoring Plan:What will be used to progress monitor? / Who is responsible? / Where will it happen? / When and how often? / Start Date
Academic:
Behavior:
Participating Team Member Signatures:
Administrator
FBA/Problem Solving Facilitator / ______
______ / Parent
Teacher / ______
______
Intervention Coordinator / ______ / Diagnostician / ______
School Psychologist / ______ / Social Worker / ______
Behavior Specialist / ______ / ______
Notes:
Date of next meeting to review data and the response to interventions:
STEP IV. Evaluation of the response to the intervention: Is it working? Meeting Date:- A. Is data graphed and sufficient to make decisions?
No: Next Step - Implement intervention and continue collecting and charting progress monitoring data
- Based on the progress monitoring data, is the student making progress toward the goal?
Yes, but goal not reached: Next Step: Continue or modify intervention until goal is met.
No improvement or got worse: Next Step: Recycle through the problem-solving process (Intervention Process Guide)
- Based on the progress monitoring data, is the discrepancy between the student and peers decreasing?
No, discrepancy increasing or Next Step: Recycle through the problem-solving process (Intervention Process Guide)
unchanged
Next Meeting Date:
PCS Form 2-3078 Page 1 of 5 (Rev. 9/13) Category Y
Review Date 9/14