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McAuliffe Behavior Tracking Form

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McAuliffe Behavior Tracking Form Powered By Docstoc
					                                          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.



                                                       Follow-up Agreement

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)

				
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