Positive Behavior Interventions & Supports Project. Intensive Individual Supports Application

Transcription

1 Positive Behavior Interventions & Supports Project School Name: School District #: Full School Address (include street/city/zip): Is school a participating RTI Site? (yes or no) School Contact: Phone Number: Address: Team Members: Include parent(s), principal, general education and special education teacher, school counselor, school psychologist, and/or other support staff important to the student s team. *Team Leader - The primary contact for the PBIS Project Coordinator and PBIS Coach Team Member Name Title/Role Address Phone Number Team Leader: School Signatures: Typed or printed name of Classroom Teacher Signature Date Typed or printed name of School Principal Signature Date Typed or printed name of District Administrator Signature Date

2 STUDENT INFORMATION: Student Name: Date of Birth (mm/dd/yyyy): Grade in School for : Is the student currently on medication? (If applicable, please list): Student Disability (if applicable): Autism Emotional Cognitive Impairment Disturbance Deaf-Blindness Health Impairment Deafness Hearing Impairment Developmental Delay Learning Disability Severe Multiple Impairments Orthopedic Impairment Speech Impairment Language Impairment Traumatic Brain Injury Visual Impairment including Blindness None District and school agree to support the school team by providing release time, as described in the administrative assurance form, during the school year. Parent Agreement: I, certify that I am aware the school is requesting support from Idaho Positive Behavior Interventions and Supports (Idaho PBIS). I understand that if this application is accepted, Idaho PBIS will help my son or daughter s school design, plan, and implement intensive, individualized behavioral interventions to help improve my child s behavior at school. I certify that I have agreed to allow my child to participate in this process. Signature: Date: Parent Consent to video (not required for application): I, agree to allow PBIS Idaho to use videotape to collect data about my son or daughter s behavior and understand that the video may be use for training purposes with PBIS Idaho staff and school staff working with children displaying challenging behavior in schools. Signature: Date:

3 Positive Behavior Intervention Supports Summary Information Nature and Severity of the Problem. Check the appropriate boxes below. If there are multiple behaviors of interest, select 1-3 of the highest impact. If target behavior is not included or not fully accounted for describe it in the space provided: Tardy Fight/physical Aggression Disruptive Theft Unresponsive Inappropriate Language Insubordination Vandalism Withdrawn Verbal Harassment Work not done Other Describe problem behavior: Verbally Inappropriate Self-injury Multiple times per day Once per day 2-5 times a week Once per week 2-4 times per month Once per month Normal Support Describe Intensity Intense but No additional adults required Multiple additional Adults required Time and location where problem is most likely (input student schedule and likelihood of target behavior(s) in the table below: Schedule (Times) Activity Likelihood of Problem Behavior Specific Problem Behavior(s) you are likely to see Low High

4 Previous Intervention(s). List all interventions both tried previously to current behavior plan as well as included on current behavior plan: Interventions prior to current behavior plan Interventions included on current plan Effective Rewards. In the space provided below list items, activities, etc. that the student seems to find rewarding: Mildly Rewarding Somewhat rewarding Extremely Rewarding Effective Consequence. In the space provided below list consequences that have been effective in the past and consequences that are currently effective: Consequences no longer effective Currently effective consequences

5 Current Educational Placement: General Education (w/no intervention) Supportive intervention in a general education classroom Supplemental intervention in a general education classroom Supplemental intervention in a resource room Part-time special education classroom Full-time special education class in a local public school Full-time special education class outside local public school Is the student currently in or being referred for special education service? If yes, please describe. Other than the disability described above, does the student receive support for any other impairment or disability? If yes, please briefly outline. Is there any other information our coach should be aware of prior to working with your team?