Targeted Intervention Checklist

1

ILLINOIS PBIS IMPLEMENTATION

Targeted Intervention Checklist

Name of School:District:

Region:NorthCentralSouthChicago Date:

System-Wide Planning

*these procedures likely will vary by school due to logistical differences

School Set-Up for Targeted Intervention / Status
Need / Partial / Done
1 / Positive behavior support systems in place to prevent problem behaviors
2 / School-wide monitoring system in place to identify problem areas, times, and conditions for students
3 / School data decision rules in place to identify students whose behaviors identify them as at-risk of failure
4 / All school personnel aware of referral and targeted intervention process
5 / *Rotating schedule for all school personnel to serve on Targeted Support Team
6 / All personnel have been exposed to the concept of function and understand access vs. escape/avoid motivation
Targeted Support Team Set-Up / Status
Need / Partial / Done
1 / Team composition
someone with administrative responsibilities
regular education personnel *by grade level or team and/or on a rotating schedule
person with behavioral knowledge/training
special ed. representation (*rotating schedule)
*counselor, school Psychologist, social worker, etc.
2 / Regularly scheduled meeting time
*weekly/bi-weekly (only when referral is pending)
3 / Set meeting location
4 / Official meetings records to be kept secure and confidential

© Terrance M. Scott, 2001

Revised February, 2001

Referral Process / Status
Need / Partial / Done
1 / Referral procedures set and in place
*what types of concerns are appropriate for referral
*how to initiate process
*deadline for referral meetings
*protocol – what information to bring to meeting
2 / Agenda
made public ahead of time
*number of students per meeting
parent(s) notified and invited to meeting

Targeted Intervention Processes

*these procedures likely will vary by student due to individual differences in referrals

Team Meeting Processes / Status
Need / Partial / Done
1 / Responsibilities
meeting leader
meeting recorder
meeting timer (optional)
2 / Protocol
*Introductions of staff, invited guests (those having contact with student)
Parent, OT/PT, mental health, medical care, etc.
record student’s strengths and weaknesses from a
variety of perspectives
determine whether information needs to be solicited from other persons
3 / Define the problem behavior(s) during meeting
observable and measurable description
description of why this is a problem
under what conditions is the problem most likely?
is an appropriate behavior ever seen under these
conditions?
4 / Complete plans for further assessment
*who, what, when, where, and how

© Terrance M. Scott, 2001

Revised February, 2001

Assessment / Status
Need / Partial / Done
1 / Start with simple and informal procedures
*interviews, questionnaires, & checklists
2 / Collaborative assessment process
*shared across team members, locations & times
assessment to focus on problems and strengths
3 / Assessment information is paired with information recorded at meeting to hypothesize function
4 / If function is not discernable, initiate more intense assessment
*direct observations (ABC functional assessments)
*environmental manipulations and analyses
5 / *Continue assessment until function is clear enough to implement an intervention
Intervention Planning / Status
Need / Partial / Done
1 / Team consensus for plan
2 / Plan is calculated to succeed
*plan is realistic given individuals and conditions
plan involves individuals from across the school
*plan involves individuals outside of school (as necessary)
3 / Plan is based on functional behavioral assessment
identify functional replacement behavior
provide access to natural reinforcement
do not allow function for inappropriate behavior
4 / Plan involves effective instructional practices
determine whether student can perform skill
teach skill and/or teach why skill is preferable
full explanation plan to student
demonstrate skill for student
range of positive natural examples
non-examples (minimally different from positive)
5 / Facilitate success
*prompts and cues provided as necessary
*arrange environment to avoid predictable failures
*arrange environment to make success more likely
provide immediate consequences for behavior
*plan to fade out prompts and artificial procedures
Monitoring and Evaluation / Status
Need / Partial / Done
1 / Determine what the student should be doing to demonstrate success
*how much, how long, at what level
*by when
*what should happen if this occurs?
2 / Determine what results would constitute plan failure
*how much, how long, at what level
*by when
*what should happen is this occurs?
3 / Determine the simplest method of monitoring behavior necessary to determine success/failure
4 / Determine responsibilities and schedule for monitoring
*who, when, where
5 / Regularly evaluate data
determine whether success or failure criteria have
been met
*make changes as decided upon above (success or
failure)

© Terrance M. Scott, 2001

Revised February, 2001

Planning for Effective Intervention

Key Concepts into Practice

Key Concepts Effective Practices

1. Identify and intervene as early s possible /

• Refer when problems or failures are first noticed
• Use assessments that lead to effective intervention

2. Be a student of the child /

• Begin with simple and informal procedures

-interviews, questionnaires,
checklists, etc.
3. Collaborate /

• Involve all persons having contact with students

-during assessment and
intervention planning
4. Start where the child is /

• Assess strengths and needs
• Prioritize needs and teach to root of problems
• Individualize instruction

5. Create a success to failure
ratio of 4:1 /

• Effective instructional practices

-modeling, example selection and
sequencing, guided practice, prompts
and cues

• Facilitate success

-structure environments to
avoid problems and
encourage success
-provide positive natural
consequences for positive
behavior
6. Have a plan and sustain it /

• Gain consensus on plans

-plans are calculated to be
successful
-plans are reasonable given
resources and conditions

• Keep plans as simple as possible while maintaining success

7. Evaluate /

• Assign data collection tasks
• Determine criteria for success and failure
• Continuous evaluation

TARGETED INTERVENTION TEAM

Request for Assistance

DateTeacher/Team

Student NameGrade/Section

Special Services:

None

___ IEP

504 Plan / ___English Language Learner
___ Speech/Language / ___ Occupational Therapy
___ Physical Therapy
___ Adaptive P.E.

Medical Issues: Does the student take medication regularly? At school?

Attendance: Number of absences current year ____ Previous year_____

Previous years report card summary:

Current Levels of Performance (current grades, grade levels):

Reading

Math

Spelling

Writing

Student Profile: Please identify at least three strengths or contributions the student brings to school (behavior/social and/or academic):

Academic Concerns:

___ Reading
___ Writing
___ Math / ___ Organization
___ Task Completion
___ Fine motor / ___ Following Directions
___ Other?
Specifically, with what type of task does the student have difficulty?

Identify problem behavior(s):

___ Tardy
___ Unresponsive
___ Withdrawn
___ Theft / ___ Fighting/Aggression
___ Inappropriate Language
___ Verbally inappropriate
Verbal Harassment
___ Vandalism / ___ Disruptive
___ Insubordination
___ Work not done
___ Self-Injury
___ Off-task
Describe the problem behavior (what does it look like?):

What have you tried to date to change the situations in which the problem behavior(s) occur?

___ Modified assignments to match the students skills / ___ Changed seating assignments / ___ Changed schedule of activities / ___ Other?
___ Arranged tutoring to improve the student’s academic skills / ___ Changed curriculum / ___ Provided extra assistance

What have you tried to date to teach expected behaviors?

___ Reminders about expected behavior when problem behavior is likely / ___ Clarified rules and expected behavior for the whole class / ___ Practiced the expected behaviors in class
___ Reward program for expected behavior / ___ Oral agreement with the student / ___ Self-monitoring program
___ Systematic feedback about behavior / ___Individual written contract with the student / ___ Contract with student and parents
Other?

What consequences have you tried to date for the problem behavior?

___ Loss of privileges / ___ Note or phone call to the student’s parents / ___ Office referral
___ Time-out / ___ Detention / ___ Reprimand
___ Referral to Social Worker / ___ Meeting with the student’s parents / ___ Individual meeting with the student
Other?

Identify Problem Routines: Where, When, and With Whom Problem Behaviors are Most Likely

Schedule (Times) / Activity / Likelihood of Problem Behavior / Specific Problem Behavior
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6

What do you think the student is getting OR getting away from by engaging in these behaviors (e.g., gain attention, gain assistance, avoid work, etc)?

Functional Assessment Checklist for Teachers and Staff

(FACTS-Part A – Problem Identification)

Student/Grade: Date:

Interviewer: Respondent(s):

Student Profile: Please identify at least three strengths or contributions the student brings to school.

Problem Behavior(s): Identify & Describe Problem Behaviors Specifically:

___Tardy
___Unresponsive
___Withdrawn / ___Inappropriate Language
___Fight/Physical Aggressive
___Verbal Harassment / ___Disruptive
___Insubordination
___Work not done / ___Theft
___Vandalism
___Other______
Describe the problem behavior(s) specifically - - What does it look like/sound like :
Identify Routines: Where, When and With Whom Problem Behaviors are Most Likely:
Schedule (Times) / Activity / With Whom does Problem Occur / Likelihood of
Problem Behavior / Specific Problem Behavior
Low High
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6

Functional Assessment Checklist for Teachers and Staff (FACTS-Part A)

Problem in Picture Form (Pro-form)

Student/Grade: Ronald/ 7th GradeDate:

Interviewer: Mrs. SnowRespondent(s):

Student Profile: Please identify at least three strengths or contributions the student brings to school.

Problem Behavior(s): Identify problem behaviors

___Tardy
___Unresponsive
___Withdrawn / ___Inappropriate Language
___Fight/Physical Aggressive
___Verbal Harassment / ___Disruptive
___Insubordination
___Work not done / ___Theft
___Vandalism
___Other______
Describe problem behavior :Gets angry at peers’ comments of, if he can’t do the class work. Strikes out at whomever made him angry. Gets in big fights-verbally and physically.
Identify Routines: Where, When and With Whom Problem Behaviors are Most Likely.
Schedule (Times) / Activity / With Whom does Problem Occur / Likelihood of
Problem Behavior / Specific Problem Behavior
8:20-9:15 / Science / Peers / Low High
1 2 3 X 5 6 / Fighting
9:20-10:15 / Math / Teacher / 1 2 3 4 5 X / Yelling, work refusal
10:20-11:15 / Reading / Teacher / 1 2 3 4 5 X / Yelling, work refusal
11:15-12:15 / Spanish / Teacher / 1 2 3 4 X 6 / Yelling, work refusal
12:20-1:00 / Lunch / X 2 3 4 5 6
1:05-2:00 / Social Studies / Peers / 1 2 3 X 5 6 / Fighting
2:05-3:00 / Physical Education / X 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6
1 2 3 4 5 6

1

1

1

1

Functional Assessment Interview Form

Interviewer(s) Mr. ChurchDate(s)10/3

Student(s) Trish

Respondent(s) Ms. Passilas Title Paraprofessional

1. Describe the behavior of concern. Trish gets mad on playground and yells at
other kids. She sometimes hits other students or kicks them. None of the kids
want to play with her.
2. How often does the behavior occur? It seems like everyday.
How long does it last? Not long. I keep my eye on her and stop her before it
Gets out of hand.
How intense is the behavior? I don’t think she has drawn blood, but she hits
and kicks so hard I get she bruises kids.
3. What is happening when the behavior occurs? Trish wants to play with others
Who are already involved in a game.
4. When/where is the behavior most/least likely to occur? It happens everywhere.
5. With whom is the behavior most/least likely to occur? Usually with other girls. I
don’t think I remember her fighting with a boy.
6. What conditions are most likely to precipitate (“set-off”) the behavior? Trish
doesn’t get her way.
7. How can you tell the behavior is about to start? She usually yells before she hits.
8. What usually happens after the behavior? Describe what happens according to adult(s), peers, and student responses. When she starts yelling, I usually make
Her stand by me for a while. If it is a major hit, I send her to the office. If
it is a shove or something like that I usually just have her stand by me.
9. What is the likely function (intent) of the behavior; that is, why do you think the student behaves this way? What does the student get or avoid? I think she does it
to get her way.
10. What behavior(s) might serve the same function (see question 9) for the student that is appropriate within the social/environmental context? She needs to learn to
wait her turn, ask nicely and control her temper. She needs to learn to make
friends,too. Nobody wants to play with her.
11. What other information might contribute to creating an effective intervention plan (e.g., under what conditions does the behavior not occur)? She’s pretty good when
she is talking with me or when she is playing games that I supervise.
12. Who should be involved in planning and implementing the intervention plan? I think
I should. I’m the one out here with her. Also, Mr. Church seems to keep her
under control while we’re in the lunchroom.

1

Functional Assessment Interview Form

Interviewer(s) Date(s)______

Student(s) ______

Respondent(s) ______Title ______

1. Describe the behavior of concern.
2. How often does the behavior occur?
How long does it last?
How intense is the behavior?
3. What is happening when the behavior occurs?
4. When/where is the behavior most/least likely to occur?
5. With whom is the behavior most/least likely to occur?
6. What conditions are most likely to precipitate (“set-off”) the behavior?
7. How can you tell the behavior is about to start?
8. What usually happens after the behavior? Describe what happens according to adult(s), peers, and student responses.
9. What is the likely function (intent) of the behavior; that is, why do you think the student behaves this way? What does the student get or avoid?
10. What behavior(s) might serve the same function (see question 9) for the student that is appropriate within the social/environmental context?
11. What other information might contribute to creating an effective intervention plan (e.g., under what conditions does the behavior not occur)?
12. Who should be involved in planning and implementing the intervention plan?

1

FUNCTIONAL INTERVIEW WITH A STUDENT

In addition to interviews conducted with adults, interviews with students may be useful in identifying how they perceive the situation and what causes them to act (or react) in the way that they do. What follows is an example of a functional interview conducted with Mandy:

Q: “Is there anything that is happening outside of school lately that bothers you”

A: “No.”

Q: “Is there something new that is happening to you?”

A: “Not really. . . . Well, we just got a new foster kid.”

Q: “Does it bother you?”

A: “No, I like playing with him and I get to feed him sometimes, too.”

Q: “What was the lesson about that was bring taught right before you made the comments that made your classroom laugh?”

A: “I don’t know, something about rocks, I think.”

Q: “What was you teacher doing?”

A: “We were discussing our homework reading assignment.”

Q: “Do you remember what were you thinking right before you made the comments?”

A: “It was just so boring!”

Q: “How do you feel about getting homework in science?”

A: “Frustrated. The book is hard to read and so I get real confused.”

Q: “Can you tell me what Mr. Smith was expecting of you during science class?”

A: “He wants us to talk about the homework, answer questions…you know, that kind of stuff.”

Q: “When you make the funny comments in class, what usually happens afterward?”

A: “Everyone laughs and looks at me. Sometimes, even Mr. Smith cracks up.”

Q: “How does that make you feel?”

A: “Pretty good. I guess I like it when the other kids notice me. I don’t know. . .”

1

Student-Directed Functional Assessment Interview

Student Name: ______Interviewer: ______

Referring Teacher: ______Date: ______.

1. Opening. “We are meeting today to find ways to change school so that you like it more. This interview will take about 30 minutes. I can help you best if you answer honestly. You will not be asked anything that might get you in trouble.”

Assist the student to identify specific behaviors that are resulting in problems in the school or classroom. Making suggestions or paraphrasing statements can help the student clarify his or her ideas. You should have a list of behaviors nominated by the referring teacher.

1. Define the behaviors of concern. * “What are the things you do that get you in trouble or are a

problem?” (Prompts: Late to class? Talk out in class? Don’t get work done? Fighting?)

BehaviorComment

1.

2.

3.

4.

5.

1. Complete student schedule. Use the “Student Daily Schedule” matrix to identify the times and classes in which the student performs problem behavior. Focus the interview on those times that are most likely to result in problem behavior.

* You will use the numbers to the left as codes for the identified behaviors as you complete the rest of the interview.

1

Student Daily Schedule

Please place an “X” in each column to show the times and classes where you have difficulty with the behaviors we talked about. If you have a lot of difficulty during a period, place an “X” on or near the 6. If you have a little difficulty during the class or hall time, place the “X” on or near the 1. We can practice on a couple together before we start.

Subject, Teacher / Before
School
_____ / 1st period
_____ / Hall
_____ / 2nd Period
_____ / Hall
_____ / 3rd Period
_____ / Hall
_____ / 4th Period
_____ / Lunch
_____ / 5th Period
_____ / Hall
_____ / 6th Period
______ / Hall
_____ / 7th Period
_____ / Hall
_____ / 8th Period
_____ / After School
_____
Most Difficult
6
5
4
3
2
Least
Difficult
1

1

SUMMARY STATEMENT FORM

PlaceActivity/EventPredictorProblem Behavior(s)Maintaining Consequences