Documentation of Effort

Student: John Doe School: Green Middle

Behavior Descriptions: Intervention Descriptions:

Negative Comments: Blurting out comments (E.g. “Shut up!”) Redirection: Verbally restate expectations (“Take out book.”)
Off-Task: Head down, sleeping, looking at materials other Support Offered: Take out materials for student/Open to page
than textbook, pacing/out of desk, going to bathroom Set Limits: State desired behavior, followed by consequence
Note: Off-task behaviors may be avoidance or sensory driven Teach Replacement Bx: Rehearse alternative behavior

DAY M T W TH F M T W TH F M T W TH F M T W TH F M T W TH F M T W TH F M T W TH F

DATE
TIME
LOCATION
Hall       
Bathroom       
Classroom (Specify)       
Other (Specify)       
ANTECEDENT/TRIGGER
Teacher Directive (e.g. ‘Take out homework’)       
Verbal Prompt/Para (e.g. ‘Get started.’)       
Staff Support Offered (e.g. ‘Do you need help?’)       
Other (Specify)       
STUDENT BEHAVIOR
Pacing/Out of Desk       
Asks for BR break or time (‘a minute’)       
Verbal Outburst       
Sleeping/Head Down       
Other (Specify)       
STAFF RESPONSE/INTERVENTION
Behavior Ignored or Request Denied       
Request Honored       
Redirected student to task       
(Restate expectation/task)
Set Limits       
(State desired behavior, then consequence)
Removed Audience/Applied Intervention
1. Step outside class
2. Allow venting       
3. Rehearse replacement behavior
4. S. asks T. permission to return to class
Other (Specify)       
STUDENT RESPONSE
Behavior Stopped (Student Complied)       
Behavior Continued       
Behavior Escalated       
Comments

Created by J. Lowe
 Documentation of Effort
Student: School:

Behavior Descriptions: Intervention Descriptions:

DAY M T W TH F M T W TH F M T W TH F M T W TH F M T W TH F M T W TH F M T W TH F

DATE
TIME
LOCATION
      
      
      
Other (Specify)       
ANTECEDENT/TRIGGER
      
      
      
Other (Specify)       
STUDENT BEHAVIOR
      
      
      
      
Other (Specify)       
STAFF RESPONSE/INTERVENTION
      
      
      
      

      

Other (Specify)       
STUDENT RESPONSE
Behavior Stopped (Student Complied)       
Behavior Continued       
Behavior Escalated       

Comments

Created by J. Lowe