McAuliffe Behavior Tracking Form
Name: _________________________________ Date: __________________ Time: ________________
Teacher: __________________________ Grade: K 1 2 3 4 5 Referring Staff: _________________________
Location Issue of Concern
◊Classroom ◊Hallway ◊Off task behavior ◊Verbal Disruption
◊Playground ◊Cafeteria ◊Not completing work ◊Non-verbal disruption
◊Bathroom ◊Bus Loop ◊Disrespectful or ◊Throwing objects/items
◊Gym ◊Music Room inappropriate comments ◊Grabbing/taking objects
◊Library / Computer Lab ◊Art Room ◊Noncompliant responses from others
◊Parking Lot ◊Assembly / Field Trip / ◊Destroying/defacing ◊Other: __________________
◊Other: ________________ Special Event property
Possible Motivation Others involved in incident
◊Obtain peer attention ◊Avoid peer attention ◊None ◊Peer (s)
◊Obtain adult attention ◊Avoid adult attention ◊Teacher ◊School Staff
◊Obtain items/activities ◊Avoid items/activities ◊Substitute ◊Unknown
◊Obtain sensory input ◊Avoid sensory input ◊Other: ________________
Description of incident:
Teacher Action / Possible Consequences
◊Apology ◊Parent Contact: ◊Conference with Student ◊Loss of privilege
◊In room recovery _______________________ ◊Think sheet ◊Verbal redirect
◊Out-of-room recovery ◊Parent/Teacher conf. ◊Administrative Referral ◊Other: ___________________
◊Delayed consequence ◊Parent obs./shadow
All Behavior Tracking Forms are filed with the classroom teacher.
Three Behavior Tracking Forms with similar possible motivation (within 1 month) result in an Administrative Referral.
Name: _____________________________________________ Date: _______________________
1. What rule(s) did you break? ◊Caring ◊Organized ◊Model respect/responsibility ◊Effort ◊Timeliness
2. What did you want?
◊I wanted attention from others. ◊I wanted to cause problems because I feel
◊I wanted to challenge adult(s). miserable inside.
◊I wanted to be in control of the situation. ◊I wanted to cause others problems because
◊I wanted to avoid doing my work. they don’t like me.
◊I wanted to be sent home. ◊I wanted ________________________________
◊I wanted revenge.
3. Did you get what you wanted? ◊ Yes ◊No
4. Who did it impact? ◊myself ◊others ◊the learning environment
5. What will you do differently next time? ________________________________________________________________
Student Signature: ________________________________ Staff Signature(s): __________________________________
◊Original to classroom teacher (blue) ◊Copy to referring staff (white) ◊Copy to parent (green) ◊Copy to principal (gold)