Brentwood Union Free School District

Brentwood, NY11717

Behavior Intervention Plan (BIP)

Date of Plan ______

Student Name ______ID # ______DOB ______

CurrentSchool ______Teacher and/or Guidance ______Grade ______

Student Address ______[ ] Brentwood [ ] Bay Shore Phone ______

Parent and/or Guardian ______Agency ______

Agency Address ______Agency Phone ______ext. ______

Agency Contact and/or Caseworker ______

Current Educational Program

This student is a [ ] Regular Education Student (not classified) [ ] Special Education Student (has a classification)

If a Special Education student, current classification is ______

Current Related Services: [ ] None [ ] Speech [ ] Counseling [ ] PT [ ] OT [ ] Other ______

Current Placement: Student is currently placed in:

[ ] General Education Program with related service(s) only

[ ] Resource Room Program

[ ] CWC (class within a class) setting

[ ] Self-Contained Setting within district ____ level I (15:1) ____ level III (15:1) level IV (12:1:1)

[ ] Self-Contained Setting OOD ____ BOCES ____ Other ______

Goals of this BIP

Based upon the results of the Functional Behavioral Assessment (FBA) it was decided to address the following goal(s).

The stated goal(s) must be measurable and observable and be derived directly from the targeted FBA behaviors.

Goal 1: ______

______

Goal 2: ______

______

Goal 3: ______

______

Behavior Intervention PlanPage 2a

Targeted Behavior # ___(Goal # ___)

BIP for Behavior # ___: ______

Behavior Identification

The following was identified as a primary problematic behavior for this student. It was agreed that this behavior is preventing this student from achieving success in their current educational setting.

Operational Definition of Behavior #___ to include frequency, duration, intensity and/or latency of the targeted behaviors: ______

______

______

Hypothesized Function of Targeted Behavior

Based upon the information and data obtained from the FBA, ______was determined to be the hypothesized function of the above noted targeted behavior.

Summary of hypothesized function of behavior

______

______

______

Intervention Procedures

Antecedent Modification: Based upon the FBA, the following were found to be antecedent and/or environmental variables that are triggering the targeted behavior: ______

These variables will be modified in the following manner: ______

______

______

______

The following staff will be responsible for this intervention: ______

______

Behavior Intervention PlanPage 2a – cont..

Replacement Behavior: The following functionally equivalent behaviors (behaviors that serve the same function as the targeted behavior and are socially more acceptable or appropriate) will be taught to this student: ______

______

______

______

The following staff will be responsible for this intervention: ______

______

Reinforcement Procedures: This student will be reinforced when the above noted replacement behaviors occur in the following manner:

[ ] Social PraiseSchedule of Reinforcement: ______

[ ] Token ReinforcementSchedule of Reinforcement ______

[ ] Prize / Tangible rewardSchedule of Reinforcement ______

[ ] Primary ReinforcementSchedule of Reinforcement ______

[ ] Activity ReinforcementSchedule of Reinforcement ______

[ ] Time with ______Schedule of Reinforcement ______

[ ] ______Schedule of Reinforcement ______

[ ] ______Schedule of Reinforcement ______

The following staff will be responsible for this intervention: ______

______

Reactive Procedures: The following intervention(s) will be implemented when the targeted behavior occurs:

______

______

______

______

The following staff will be responsible for this intervention: ______

______

Behavior Intervention PlanPage 2a – cont..

Data Collection: To ensure the effectiveness of the above prescribed BIP, data on the targeted behavior will be kept in the following manner:

______

______

______

______

The following staff will be responsible for data collection:______

______

Monitoring of Plan

This Behavior Intervention Plan will be monitored as outlined in the schedule below. The BIP team should review the effectiveness of the intervention(s) including a review of the frequency, duration and intensity data of the targeted behavior.

Monitoring Schedule: ______

The BIP team has established the following person to facilitate the progress monitoring: ______

Progress Report To Parent

The parent will be provided a written progress report on this BIP on a ____ Quarterly ____ Other basis.

Behavior Intervention PlanPage 3a

Targeted Behavior # ___ (Goal # ___)

BIP for Behavior # ___: ______

Behavior Identification

The following was identified as a primary problematic behavior for this student. It was agreed that this behavior is preventing this student from achieving success in their current educational setting.

Operational Definition of Behavior #___ to include frequency, duration, intensity and/or latency of the targeted behaviors: ______

______

______

Hypothesized Function of Targeted Behavior

Based upon the information and data obtained from the FBA, ______was determined to be the hypothesized function of the above noted targeted behavior.

Summary of hypothesized function of behavior

______

______

______

Intervention Procedures

Antecedent Modification: Based upon the FBA, the following were found to be antecedent and/or environmental variables that are triggering the targeted behavior: ______

These variables will be modified in the following manner: ______

______

______

______

The following staff will be responsible for this intervention: ______

______

Behavior Intervention PlanPage 3a – cont..

Replacement Behavior: The following functionally equivalent behaviors (behaviors that serve the same function as the targeted behavior and are socially more acceptable or appropriate) will be taught to this student: ______

______

______

______

The following staff will be responsible for this intervention: ______

______

Reinforcement Procedures: This student will be reinforced when the above noted replacement behaviors occur in the following manner:

[ ] Social PraiseSchedule of Reinforcement: ______

[ ] Token ReinforcementSchedule of Reinforcement ______

[ ] Prize / Tangible rewardSchedule of Reinforcement ______

[ ] Primary ReinforcementSchedule of Reinforcement ______

[ ] Activity ReinforcementSchedule of Reinforcement ______

[ ] Time with ______Schedule of Reinforcement ______

[ ] ______Schedule of Reinforcement ______

[ ] ______Schedule of Reinforcement ______

The following staff will be responsible for this intervention: ______

______

Reactive Procedures: The following intervention(s) will be implemented when the targeted behavior occurs:

______

______

______

______

The following staff will be responsible for this intervention: ______

______

Behavior Intervention PlanPage 3a – cont..

Data Collection: To ensure the effectiveness of the above prescribed BIP, data on the targeted behavior will be kept in the following manner:

______

______

______

______

The following staff will be responsible for data collection:______

______

Monitoring of Plan

This Behavior Intervention Plan will be monitored as outlined in the schedule below. The BIP team should review the effectiveness of the intervention(s) including a review of the frequency, duration and intensity data of the targeted behavior.

Monitoring Schedule: ______

The BIP team has established the following person to facilitate the progress monitoring: ______

Progress Report To Parent

The parent will be provided a written progress report on this BIP on a ____ Quarterly ____ Other basis.

Behavior Intervention PlanPage 4

Agreement

The below have participated in the development of the Behavior Intervention Plan (BIP). All of the undersigned agree that BIP was developed to address the targeted behavior(s) in relation to the hypothesized function of the behaviors and/or the effects of the environment.

Team Members (please print name)Signatures of Team MembersDate

______/____/____

______/____/____

______/____/____

______/____/____

______/____/____

______/____/____

Attachments:Informed Consent

Summary of Parent Conference (if parent did not attend the FBA meeting)

Revised 9/22/08