Behavior Support Plan Template Form Lebanon by umz20306

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									Lebanon High School




   Staff Support Team

  Level II Staff Process
                              TABLE OF CONTENTS

Letter from the Principal................................................................              3

Referral Process………………………………………………….                                                                   4

SST Referral Checklist..................………………………………                                                   5

Meeting Process........…………………………………………….                                                              6

Role Responsibilities.....................………………………………                                               7,8

Data Collection Form (two sided)......…………………………...                                                 9, 10

Data Collection Summary..………………………………...........                                                      11

Administrator Notification Form...................................................                    12

Counselor Notification Form.........................................................                  13

Functional Behavior Plan (FBA) Template...……………………                                                    14

Behavior Support Plan (BSP) Template........................................                          15

Parent Notification Form...............................................................               16

Parent Worksheet...........................................................................           17

SST Meeting Reminder.................................................................                 18

Appendix........................................................................................       19
  Intervention Programs………………………………………...                                                              20
  Red Card Behavior Support Program………………………...                                                        21
  “Head’s Up” Form……………………………………………                                                                    22
  Intervention Checklist...............................................................                23
  What Makes SST’s Effective....................................................                       24
  SST Tasks.................................................................................           25
  Functional Behavior Assessment Sample.................................                           26, 27
  Behavior Support Plan Sample.................................................                        28
  Problem-Solving Form Sample................................................                          29
  Bimonthly Progress Report Sample..........................................                           30
  Daily Progress Report Sample..................................................                       31

                                                        2
To:   All Staff


From: Ken Woody


The purpose of the Staff Support Team
is to support teachers with additional
strategies, interventions, and skills
in working with students who have
demonstrated persistent behavior
problems. The Staff Support Team is
teacher centered and is a resource for
continued personal support for teachers
who have extended themselves in the
classroom and find no further
alternatives. Referrals for this
staffing are primarily based on social-
emotional behavior problems, but may be
made for academic reasons in some
cases.

Acknowledgment is given to Lebanon High
School staff for all their efforts in
managing student’s behaviors. In
support of that, this manual has been
                   3
developed through the efforts of Cory
Dunn, Anne Johnson, Kerry Luber, Janet
Pickinpaugh, Leanne Raze, Kate Rey,
Jenny Scholl, and Jan Silverio.




                   4
                           Lebanon High School
                    Staff Support Team (SST) Staffing
                                    Referral Process

Introduction: This is the procedure for getting help for students who are experiencing
behavior problems in your class. If your classroom interventions are not working (see step
1), team up with the student’s counselor, or Special Education case manager (if a Special
Education student) and proceed to step 2.

Step 1. Teachers try Level I (classroom interventions), e.g. meeting with student, Effective
Behavior Support (EBS) strategies, and others (please refer to the Intervention Checklist for
additional suggestions). Teacher meets with the student’s counselor, designated case
manager, or administrator for additional ideas to try.

Step 2. Decide if the student is experiencing difficulties in other settings:
• The counseling secretary gathers printouts for attendance, academic grade history, and
   behavior.
• The teacher and counselor, administrator, or designated case manager reviews this
   information to decide whether to refer for a SST staffing.

Step 3. When a SST referral is made, the steps on the next page are completed.




                                              5
 STAFF SUPPORT TEAM REFERRAL CHECKLIST

Student:                                     Staffing scheduled for
                                                                            (Date)

STUDENT #                             Age:            DOB:                        M       F

Primary Language:                                     {504? Yes    No} {Sp/Ed? Yes            No}

Counselor: _______________________ Spec Ed Case Manager: ________________________

# Credits to Date                      # Years in High School:

(Circle One)          Freshman               Sophomore            Junior         Senior

Type of School Program (Circle): Modified Diploma Program                  GED

LHS Standard Diploma                 Basic Credit Option          LBCC Basic Adult Diploma

Agency Staff Name (Juvenile, Mental Health, etc)

SST Referral Checklist:

Data sources and summaries necessary for a SST Staffing:

  θ        Detention (Room 24) behavior records (sign-in sheet)_______________________
           __________________________________________________________________
  θ        Behavior records (from AS 400 or SWIS) ________________________________
           __________________________________________________________________
  θ        Attendance records (from AS 400)______________________________________
           __________________________________________________________________
  θ        Grade transcript/grade history (from AS 400) _____________________________
           __________________________________________________________________
  θ        SST data collection forms, including attached Behavior Plans, Head’s Up forms,
           and/or Red Card Program_____________________________________________
           __________________________________________________________________
  θ        If Special Education identified, a copy of their latest Individual Education Plan
  θ        Student Interview
  θ        Parent interview
  θ        Functional Behavior Assessment filled out using data from sources listed above
  θ        Referral to ESD Behavior Management or Family Support Programs
  θ        Referral to Linn County Mental Health or Physician for assessment




                                                     6
                        Lebanon High School
                  Staff Support Team (SST) Staffing
                                 Meeting Process



The following steps outline the SST staffing process that is designed to take
45 minutes.


1. Facilitator introduces participants, describes the meeting process (including
   the scribe behind the laptop and why teachers may enter and exit throughout
   the meeting) and summarizes the information from the Functional Behavior
   Assessment (FBA).

2. Any additional information, clarifications and/or modifications are added to
   the FBA.


3. Brainstorm alternatives for intervention strategies and select the ones to
   include in the Behavior Support Plan (BSP).


4. Create a BSP that establishes who will do what by when.


5. Select a plan monitor.


6. Print and distribute BSP to parent(s) and staff members as soon as possible.




                                         7
                          Lebanon High School
                    Staff Support Team (SST) Staffing
                                  Role Responsibilities

The following definitions of roles are intended to clarify everyone’s responsibilities in
making the SST staffing process beneficial and efficient.

Referring Staff Member:
• Tries Level I (Classroom interventions) before making a referral.
• Arranges to attend the SST staffing.
• Actively participates in the SST staffing.

Meeting Facilitator:
• Starts the meeting on time.
• Makes introductions and describes the meeting process.
• Keeps the meeting moving along so the agenda is accomplished on time.
• Assists in maintaining a positive, productive meeting climate.

School Counselor, Designated Case Manager or Administrator:
• Upon receiving the referral, distributes SST data collection forms to student’s other
   teachers.
• Reviews the SST data collection forms and other sources of information to determine if
   this referral is appropriate for a SST staffing.
• Is available to meet the parent(s) and students when they arrive on the day of the meeting,
   and escort them to the meeting room.
• Upon notification of the referral, notifies parent(s) of the Level II staffing, and mails
   them a parent worksheet.

Scribe:
• Before the meeting, sets up a laptop computer containing the Functional Behavior
   Assessment (FBA) and Behavior Support Plan (BSP) template, in the meeting room.
• During the meeting, captures the essence of what is said, on the BSP form.
• As soon as possible, prints out copies of the BSP and distributes them to the meeting
   participants and the mailboxes of staff working with the student staffed.

Administrator and Counselors: (When not initiating the referral process)
• Completes the Administrator Notification form and either forwards it to another
  administrator who is familiar with the student or returns it to the person who sent it.



                                              8
Support Staff:
• Provides student’s class schedule, home address and phone number to the staff member
  responsible for writing the Functional Behavior Assessment.
• Schedules the staffing and notifies student’s teachers, administrator, and counselor of the
  staffing date.
• Obtains student’s Attendance Profile, Academic Record and Behavior Record and sends
  them to the Administrator, Counselor or designated Case Manager.

Plan Monitor:
• Receives “status reports” from BSP participants and determines:
   1. If the plan is being implemented as written,
   2. If other action needs to be taken,
   3. If additional support is needed.

 Parent:
• Arrives prepared to work as a member of the education team to support their student.
• Actively participates in the staffing.
• Follows through with their piece of the BSP.
• Contacts the Plan Monitor if changes are needed.

 Student:
• Attends the staffing with an open mind, a willingness to describe what’s going on for
   them, and to consider ideas that might be helpful.
• Follows through with their piece of the BSP.
• Contacts a staff member or a parent to let them know if something about the plan is not
   working.

Staff:
 • Actively participates in the staffing. If unable to attend, provides the information to
   another staff member who will attend.
• Follows through with their piece of the BSP.
• Contacts the Plan Monitor if changes are needed




                                               9
          Staff Support Team (SST) Data Collection Form
Student: _______________________________ Period: _______ Grade: 9 10 11 12 Date: ____________
Staff Member: __________________________ Subject: ___________________ Approximate Grade: ____
Please Return to:                                                       By: ________________

Student Strengths:
     Stays on task                     Good study skills                   Willing to try
     Doesn’t give up                   Listens to instructions             Organized
     Attends regularly                 Asks for help, when needed          Quality work
     Peer relations                    Adult relations                     Pride in appearance
     Other:


Problems or Concerns:
     Academic                          Citizenship                         Very active
     Missing/late assignments          Poor Peer/Social Interactions       Tardy/Absent
     Low quality work                  Language (Derogatory/profanity)     Violent/Aggressive
     Doesn’t participate               Easily angered                      Defiant/argumentative
     Easily frustrated                 Medical/Heath concerns              Poor appearance
     Other:


Conditions that make the concern more likely to occur:
   Reprimand/Correction          Long tasks                Hard tasks      Easy tasks
   New Concepts                  Repetitive tasks          Working alone   Working with peers
   Sitting by certain peers      Transitioning             Writing         Reading
   Unstructured time             Other:


What maintains the concern? (What function does it serve?)
Things that are Obtained                     Things Avoided or Escaped From
         Adult attention                                Hard tasks
         Peer attention                                 Reprimands
         Preferred activity                             Peer negatives
         Property                                       Accountability
         Status                              Other:


Additional Comments:




Suggested Solutions to the Problems/Concerns:




                                      Please fill out other side
                                                 10
                                    INTERVENTION CHECKLIST
STUDENT                                         TEACHER
                 Please check the intervention strategies you have already tried

             ACADEMIC INSTRUCTION                                       TEACHER REINFORCERS
 μ    Planner assignment sheet required
 μ    Small Group Instruction                                  μ    Positive feedback for responsible behavior
 μ    Individualized instruction/directions                    μ    Encouragement techniques
*μ    Determined that instructional program is                 μ    Daily effort report between teacher & student
      appropriate to student’s academic needs                  μ    Weekly effort report between teacher & student
μ     Modify curriculum                                        μ    Reinforce correct responses promptly
      μ             Lower level of text                        μ    Choice of how to complete assignment
      μ             Taped instructional stories                μ    Positive note sent or called home
      μ             Other __________________________           μ    Class-wide reinforcement system
                                                               μ    Other (Specify) _________________________
μ     Modify or shorten assignments
μ     Coordinate with Study Skills Staff
μ     Change grouping                                               TEACHER CLASSROOM MANAGEMENT
μ     Cooperative learning or peer tutoring                    *μ   Rules and consequences for managing student
μ     Academic leave                                                  behavior are posted and taught in classroom
                                                               *μ   Teacher checks for understanding of the
μ     Other (Specify) _____________________________                 expectations and consequences
      __________________________________________               μ    Teacher consistently reinforces classroom
                                                                    expectations and rules
                                                               μ    Teacher uses brief, simple, direct commands
                    BUILDING SUPPORT
μ    Weekly/Bi-monthly teacher progress reports through
     health office secretary                                    WHEN PROBLEM WITH INDIVIDUAL STUDENT
                                                                OCCURS:
μ    Special programs                                          μ Teacher has met privately with student to
     μ           S.A.L.T. staffing                                problem solve and develop a plan for student
     μ           Structured Study Hall                              improvement       Oral    Written
     μ           Red Card Behavior Support Program             μ    Teacher contacts Parent
     μ           Section 504 eligibility screening             μ    Other: (specify) _________________________
     μ           Education Testing- Special Ed Referral
μ    Attendance Referral
μ    Counseling Referral                                                 NEGATIVE CONSEQUENCES
μ    Advisor Referral                                          μ    Low key verbal correction
μ    Other (Specify) _______________________________           μ    Planned ignoring
                                                               μ    Talk with student about problem
                                                               μ    Self-report behavior form
                                                               μ    Isolation within the classroom
                                                               μ    Clarification of rules
                                                               μ    Carrel – to eliminate distractions
                    PARENT CONTACT                             μ    Move to different seat
μ    Letter or email home                                      μ    Seat student near teacher desk
μ    Telephone conference                                      μ    Time-out
μ    Parent/teacher conference                                 μ    Problem solving- Referral to Room 24
     OR                                                        μ    Refer to administrator on Discipline Action Form
μ    Parent/teacher/student conference                         μ    Other (specify) __________________________

                                                          11
μ    Other (specify) ______________________________


*Required staff interventions prior to referral for Level II (SST) Staffing




                                                      12
       Staff Support Team (SST) Data Collection Summary
                             (Tabulated from Data Collection Forms)
Student: _____________________________________ Total Number of Teachers Responding: ________
Staff Member Summarizing: ______________________________________ Date: __________________
                      Please indicate the number of responses for each area

Student Strengths:
     Stays on task                    Good study skills                  Willing to try
     Doesn’t give up                  Listens to instructions            Organized
     Attends regularly                Asks for help, when needed         Quality work
     Peer relations                   Adult relations                    Pride in appearance
     Other:


Concerns:
      Academic                         Citizenship                        Very active
      Missing/late assignments         Poor Peer/Social Interactions      Tardy/Absent
      Low quality work                 Language (Derogatory/profanity)    Violent/Aggressive
      Doesn’t participate              Easily angered                     Defiant/argumentative
      Easily frustrated                Medical/Heath concerns             Poor appearance
      Other:


Conditions that make the concern more likely to occur:
   Reprimand/Correction          Long tasks              Hard tasks       Easy tasks
   New Concepts                  Repetitive tasks        Working alone    Working with peers
   Sitting by certain peers      Transitioning           Writing          Reading
   Unstructured time             Other:

What maintains the concern? (What function does it serve?)
Things that are Obtained                     Things Avoided or Escaped From
         Adult attention                                Hard tasks
         Peer attention                                 Reprimands
         Preferred activity                             Peer negatives
         Property                                       Accountability
         Status                              Other:


Comments:




                                                13
                            Lebanon High School
                     Staff Support Team (SST) Staffing
                           Administrator Notification Form


To:   Ron Williams (A-Gri)        Leanne Raze (Gro-O)       Ed Mendelssohn (P-Z)

(Please circle the administrator assigned to the student by first letter of student’s last name)


Date: _________________           Re: ________________________________
                                             (Student’s Name)

The SST Staffing will be held at 7:30 a.m. on                              .

If another administrator is familiar with this student, please pass this on to that person
after you have finished.

Please check the appropriate line below and attach any information you would like
considered in this staffing.
____ No contact with this student
____ Contact made, but no relevant information
____ Please see me
____ Information attached
____ I will attend the SST staffing

Please sign, date and return to                                     by ______________.

_________________________________                           __________________
            Signature                                              Date

 Comments:




                                                14
                            Lebanon High School
                     Staff Support Team (SST) Staffing
                              Counselor Notification Form


To: Bonnejo Ixtacuy (A-Gri) Lorna Torrey-Palermo (Gro-O) Jeannie Evans-Todahl (P-Z)

(Please circle the counselor assigned to the student by first letter of student’s last name)


Date: _________________           Re: ________________________________
                                             (Student’s Name)

The SST Staffing will be held at 7:30 a.m. on                             .

If another counselor is familiar with this student, please pass this on to that person
after you have finished.

Please check the appropriate line below and attach any information you would like
considered in this staffing.
____ No contact with this student
____ Contact made, but no relevant information
____ Please see me
____ Information attached
____ I will attend the SST staffing

Please sign, date and return to                                     by ______________.

_________________________________                           __________________
            Signature                                              Date

Comments:




                                                15
                                Lebanon High School
                         Functional Behavior Assessment
                                (Template from Laptop Computer)
Student:               Grade:                Date:

The purpose of a functional behavior assessment is to gain a better understanding of why someone, in this
case, (student’s name) is engaging in problem behaviors.

The information in this report was obtained from ...

Strengths/Interests:
•

Target Behaviors (Areas): Target behaviors are those behaviors that are of concern and are seen as
preventing (student’s name) from experiencing higher levels of success at school.
•

Set Up’s (Setting Events): Set Up’s are conditions or events that appear to predispose (student’s name) to
exhibit target behaviors when antecedents occur.
•

Set Off’s (Antecedents): Set Off’s are the events that occur immediately before the target behaviors, the
majority of the times.
• .

Hypothesis: The hypothesis uses the information gathered, to form connections that explain the underlying
purpose(s) of the (student’s name) behavior.




                                                       16
                              Lebanon High School
                                Behavior Support Plan
                              (Template from Laptop Computer)

Student:             Grade:               Date:

Hypothesis: When
                           (Setting events)                (Student)             (Behavior)

______________________in order to                                                             .
                                                  (Obtain or escape what?)

1) Desired Behaviors:
   A.
   B.
   C.

                                                  Action                             Who
2) Strategies/Accommodations:
   A. School (Consider instruction, curriculum, environment)

   B. Home

   C. Agency

3) Skill Development:
   •

4) Positive Incentives:
   •

5) Procedures for managing inappropriate behavior:
      Step 1:
      Step 2:
      Step 3:

6) Measuring Plan’s Effectiveness (Data Collection):

7) Safety Support Plan: (If needed, for how to prevent and respond to dangerous behavior)




                                                  17
                          Lebanon High School
                    Staff Support Team (SST) Staffing
                                Parent Notification Form

Date: _______________

Dear __________________________,

Recently some school staff have expressed concerns regarding your child’s educational
performance. We would like them to be successful in school and consequently we will be
holding a SST Staffing on __________________ at _________o’clock to find ways we can
further support _____________________________.

This staffing takes about 45 minutes. During the first 5 minutes, we will review information
gathered from a variety of sources. During the next 20 minutes, we will brainstorm how
additional support can be provided. During the next 15 minutes, we will create the Behavior
Support Plan (BSP). For the last 5 minutes, we will review the BSP. Typically, the way we
gather information for this staffing is by conducting a Functional Behavior Assessment
(FBA), which may include classroom observations; parent, teacher, and child interviews;
and a review of education records.

Your ideas are highly valued and we would appreciate your participation. To assist in that
regard, we’ve included a “Parent Worksheet.” Many parents find it a useful tool to assist in
organizing their ideas before the meeting. It is intended solely for your personal use and
does not get distributed to others. It may be helpful to you to fill out the Parent Worksheet
and bring it with you to the meeting. Please sign and bring this form with you to the SST
staffing.

We are looking forward to working together so your student obtains maximum benefit from
their high school education. Please call me at the school at 451-8555 if you have any
questions or are unable to attend.

Thank you,



I have read and understand the description of how the staff will collect and organize the
information needed to conduct a SST staffing process. I grant permission for the education
staff to collect the information and to hold a SST staffing on my son/daughter.


             Parent signature

                                             18
                          Lebanon High School
                    Staff Support Team (SST) Staffing
                                   Parent Worksheet

This worksheet is intended to assist you in preparing for the staffing for your student.
Please take a few minutes to fill it out and bring it with you to the staffing. Your input
is a highly valued part of this staffing.

1. What are your critical concerns/questions for your son/daughter?




2. What do you see as your student’s strengths (current and past)?




3. Do you have any idea regarding the underlying reasons for your son’s/daughter’s current
   struggles in school?




4. What are your ideas for creating positive change or providing additional support for your
   child?




                                             19
                                  SST Meeting Reminder
This is a reminder of the SST staffing on (student’s name) scheduled for (date & time).
Thank you very much for your input on the SST Data Collection form.

I.     What to expect at the SST staffing? A SST staffing has three parts:
       1. The participants introducing themselves and the facilitator summarizing the information
          collected.
       2. An opportunity for staff to update information not collected previously.
          In order to make the best use of our time, we need to avoid reexplaining problems or telling
          stories to illustrate problems.
       3. Brainstorm solutions to create an action plan that offers solutions to the problems.

Section III lists the parts of a SST Action Plan. If you can attend the staffing, it can be helpful to organize
your thoughts under the appropriate headings. If you won’t be able to attend, please fill in section II and put
it in Jan Silverio’s mail box.

II.    Information Update:
       1. Current Grade: A B        C      D     F      Missing Assignments: No             Yes
       2. Behavior/Attitude: No change from SST Data Collection form
                    Changed from the SST Data Collection form      Please explain




III.   SST ACTION PLAN

Hypothesis: (Our best guess as to why we think the student is engaging in problem behaviors)


Desired Behaviors: (What behaviors would cause this student to be successful in your class?)



Strategies/Accommodations: (What can we do to help the student be more successful)



Skill Development: (What skills might the student need to use the desired behaviors)



Positive Incentives: (Things the student is willing to work to get)



Managing problem behaviors: (Additional ideas to the regular discipline procedures)



                                                      20
APPENDIX




   21
                            Lebanon High School
                              Intervention Options

   Intervention:                          Description:

1. Red Card Behavior         Allows select students to initiate a “time-out” using
   Support Program           minimum verbalization: a self-management tool.

2. “Head’s Up” form          Communicates to all a student’s teachers, prevention and
                             response strategies to deal with maladaptive behaviors.

3. Section 504 Plans         Accommodation/Adaptation Plans for
                             disabled students that meet the criteria.

4. Structured Study Halls    Provides structured study time for students
                             to complete classroom work or homework.

5. Credit Recovery (CSC)     Allows students to concentrate on gaining
                             credits they need to graduate.

6. LBCC GED Program          Allows students to focus on earning a GED
                             in lieu of a regular High School diploma.

7. Credit Recovery           Allows students to concentrate on gaining
   (Marty Mundy)             credits they need to graduate.

8. Youth Services Team       Interagency staffing for students and their
                             families needing community support.

9. School Counselors         Provide a wide range of services from class
                             scheduling to assessment and referral for
                             complex concerns.

10. S.A.L.T. Staffing        Screenings for students being considered for
                             Alternative Education Options.

11. Staff Support Team       A level II (building level) staffing to
                             develop interventions to assist students
                             who are struggling.




                                           22
                                                    Red Card Behavior Support Program
Case Manager:                                                                                                       Date:

Program description: The “red card” is a permanent pass that a select few students carry as part of their
Behavior Support Plan. A team of staff members will determine which students need this plan and who will
monitor it. These students may use it to initiate a “time-out” from an interaction with an adult to avoid
his/her escalating, but maintain accountability for the student.

Purpose: The purpose of the “red card” is to indicate non-verbally to a staff member that the student needs
to go immediately to a pre-designated area for adaptive problem solving. A staff member will be there to
supervise a problem-solving process agreed on by the student in advance. The student must then re-engage
with the first adult to finish the original interaction.

The “red card”:
       DOES allow the selected student to communicate non-verbally
       DOES allow the student, before he/she gets out of control, to leave an interaction or area to go to a
              pre-determined location for problem solving before returning to finish the original interaction
       DOES NOT allow the student to avoid completing interactions or avoid assuming responsibility for
              his/her actions
       DOES allow the staff member to determine that the situation with the student is dangerous and
              supercedes and nullifies the “red card”
       DOES allow the original staff member to either supervise the student to the designated area or
       allow
              the student to go to this area and just notify the staff in this area that the student is coming

Once in the “time out” location, the student will complete the Problem Solving Action Plan below, review it
with the staff in the “time out” location and then the original staff member in the interaction, who will sign
off when the student has met his/her responsibility for completing the “red card” plan. The student’s case
manager will be informed of the use of this plan by the student.


                                                                                                               PROBLEM-SOLVING ACTION PLAN
                                                                            Student:                                                 Date:
                                                                            Teacher:
                     PASS TO PREDETERMINED PLACE,




                                                                            1.   This is what I wanted


                                                                            2.   This is my plan for getting what I want appropriately, next time
                                                    RED CARD SUPPORT PLAN
                     RM 24 MAIN OFFICE




                                                                            3.   I need this assistance
    EFFECTIVE DATE




                                                                                 From

                                                                            4.   TEACHER: This plan is OK with me if


                                                                            Signatures indicate the plan has been completed successfully
    NAME:




                                                                            STUDENT

                                                                            TEACHER

                                                                            DATE



                                                                                                      23
                                                                                    CONFIDENTIAL
                                          “HEADS UP”
                                    from Spec. Ed. /Counselors
             This information is being provided to alert you to a student with special needs.

Re:                                                                         Date:
θ IEP                                          θ 504                        θ Neither
Behavior Concerns:
  Doesn’t follow rules                             Very active                    Physically aggressive *
  Bothers other students                           Bullies                        Fire Setting
  Blurts out                                       Easily frustrated              On a Behavior Plan
  Steals                                           Short anger fuse
  Harasses *                                       Argumentative
Behavior Focus:
  To seek positive attention from peers                         To use appropriate language
  To seek positive attention from adults                        To treat others respectfully
  To follow class/school rules                                  To use time productively
  To maintain self control, stay focused
  To problem-solve difficulties

Do This As Soon As Possible To Encourage Pro-social Behavior:




Academic Issues                               Strengths
  Tries hard to do a good job             Visual Learner          Knows how to use accommodations
  Hands-on learner                        Organized

   Grade Level Skills in          Reading         Math         Writing          Other

Academic Goals
  To ask for help when needed                                   To turn in work when due
  To listen when teacher is talking                             To use accommodations properly
  To improve organization skills                                To improve study skills
  To begin work when assigned                                   To follow directions
  To complete work on time                                      To increase work quality


Student Responds Well To:



Contact Person(s):                                                     at

*Please see the contact person as soon as possible.
Further information may be copied on the back or attached
                                                        24
                                 INTERVENTION CHECKLIST
STUDENT                                         TEACHER
                 Please check the intervention strategies you have already tried

             ACADEMIC INSTRUCTION                                       TEACHER REINFORCERS
 μ    Planner assignment sheet required
 μ    Small Group Instruction                                  μ    Positive feedback for responsible behavior
 μ    Individualized instruction/directions                    μ    Encouragement techniques
*μ    Determined that instructional program is                 μ    Daily effort report between teacher & student
      appropriate to student’s academic needs                  μ    Weekly effort report between teacher & student
μ     Modify curriculum                                        μ    Reinforce correct responses promptly
      μ             Lower level of text                        μ    Choice of how to complete assignment
      μ             Taped instructional stories                μ    Positive note sent home
      μ             Other __________________________           μ    Class-wide reinforcement system
                                                               μ    Other (Specify) _________________________
μ     Modify or shorten assignments
μ     Coordinate with Study Skills Staff
μ     Change grouping                                               TEACHER CLASSROOM MANAGEMENT
μ     Cooperative learning or peer tutoring                    *μ   Rules and consequences for managing student
μ     Academic leave                                                behavior are posted and taught in classroom
                                                               *μ   Teacher checks for understanding of the
μ     Other (Specify) _____________________________                 expectations and consequences
      __________________________________________               μ    Teacher consistently reinforces classroom
                                                                    expectations and rules
                                                               μ    Teacher uses brief, simple, direct commands
                    BUILDING SUPPORT
μ    Weekly/Bi-monthly teacher progress reports through
     the health office secretary                                WHEN PROBLEM WITH INDIVIDUAL STUDENT
                                                                OCCURS:
μ    Special programs                                          μ Teacher has met privately with student to
     μ           S.A.L.T. staffing                                problem solve and develop a plan for student
     μ           Structured Study Hall                              improvement       Oral    Written
     μ           Red Card Behavior Support Program             μ    Teacher contacts parent
     μ           Section 504 eligibility screening             μ    Other (specify) _________________________
     μ           Education Testing- Special Ed Referral
μ    Attendance Referral
μ    Counseling Referral                                                 NEGATIVE CONSEQUENCES
μ    Advisor Referral                                          μ    Low key verbal correction
μ    Other (specify) _______________________________           μ    Planned ignoring
                                                               μ    Talk with student about problem
                                                               μ    Self-report behavior form
                                                               μ    Isolation within the classroom
                                                               μ    Clarification of rules
                                                               μ    Carrel – to eliminate distractions
                    PARENT CONTACT                             μ    Move to different seat
μ    Letter or email home                                      μ    Seat student near teacher desk
μ    Telephone conference                                      μ    Time-out
μ    Parent/teacher conference                                 μ    Problem solving- Referral to Room 24
     OR                                                        μ    Refer to administrator on Discipline Action Form
                                                          25
μ    Parent/teacher/student conference                       μ    Other (specify) __________________________
μ    Other (specify) ______________________________


*Required staff interventions prior to referral for Level II (SST) Staffing


                                Lebanon High School
                        Staff Support Team (SST) Staffing

             Variables That Make Staff Support Teams (SST) Effective

1. At the start of each staffing, clarifying the meetings’ objectives, the meeting process, and what each
   participant will gain, e.g. parents gain a better understanding of their student’s behavior in school and
   teachers gain a better understanding of conditions influencing school behavior, everyone working
   together on common goals, etc. This can prevent misperceptions, such as a parent thinking the teachers
   don’t care because they are arriving late and/or leaving early in order to attend to their classes.

2. Beginning the meeting by reviewing an accurate, comprehensive description of the student (from the
   Functional Behavior Assessment) establishes the precedent that participants can speak honestly about
   any issue they believe will contribute to a successful intervention.
   • A parent interview is absolutely mandatory to achieve this
   • A honest description written in a way that’s sensitive to those being described, facilitates the parent
      and student feeling understood rather than judged

3. Administrative support, understanding, and sanction of the SST process.

4. Breaking down the we—them divide between parents and school staff. Parents feel heard and better
   understood and school staff better understand when the “Set-up’s” (issues impacting the student) are
   acknowledged. These include neurobiological influences, medical needs, past traumas, family issues, a
   history of school difficulties, etc.

5. A quality Functional Behavior Assessment can provide the level of specificity necessary to create
   specific interventions for the Behavior Support Plan that are easier to measure when implemented.

6. All participants receiving a copy of the Behavior Support Plan as soon as possible provides immediate
   positive evidence that their time and efforts were well spent.

7. A parent willing to participate. Sometimes, parents don’t start out this way. However, we’ve found
   that as they provide information for the FBA during the parent interview, they often become more
   willing to work with the school.




                                                      26
                               Lebanon High School
                       Staff Support Team (SST) Staffing

                                                  Tasks

1. Student prioritizing & referral to SST

2. Student data requests, including attendance, academic, and behavior records

3. Detention data collection and summary

4. SST Data Collection Form (distributed to each teacher)

5. Summarizing the data collected from teachers

6. Administrator interview

7. Counselor interview

8. Education file review

9. Student interview

10. Parent orientation, permission to staff, and making interview appt.

11. Parent interview and forms filled out

12. If Special Education, copy of IEP

13. Information from agency folks (if involved)

14. Writing the Functional Behavior Assessment

15. Sending reminders to staff about the SST meeting

16. SST staffing

17. Debriefing the staffing

18. Writing the Behavior Support Plan (BSP)

19. Distributing the BSP

                                                     27
20. Implementing the BSP

21. Evaluating if the BSP is working




                                       28
                  Functional Behavior Assessment Sample

Name: Troubled Timmy                        Grade: 10th                          Date: 01/01/01

The purpose of a functional behavior assessment is to gain a better understanding of why someone, in this
case, Timmy, is engaging in problem behaviors.

The information in this report was obtained from interviews with Timmy, his mother, Tori, six of Timmy’s
teachers, Timmy’s school counselor, and administrator and from his education records.

Strengths:
• Smart (High average range)                Tolerant of peer’s shortcomings
• Basketball                                Enjoys helping peers that are struggling
• Athletic abilities                        Parents set limits and provide consequences
• Respects females                          Writing poetry
Interests:
• Baseball                                  Rollerblading
• Video games                               Writing poetry
• Skateboarding                             Basketball
• BMX riding

Target Behaviors: Target behaviors are those behaviors that are of concern, and are seen as preventing
Timmy from experiencing higher levels of success at school.
• Excessive absences, skipping and tardies
• Anger issues
• Not asking for help with academics
• Not making up missed work

Set Up’s: Set Up’s are conditions or events that appear to predispose Timmy to exhibit target behaviors
when “Set Off”.
• Gets depressed
• Doesn’t love himself (from how mom sees him)
• Long history of school problems (identified as E.D. in the 3rd grade)
• Difficulty trusting and respecting men
• Feels his emotions’ deeply, but rarely talks about them
• Puts other’s (friend’s and families) needs before his own
• Hangs with peers who get in trouble
• Recent tough news regarding his health and the courts
• Often doesn’t get enough sleep
• Suffers severe headaches
• Being negatively judged by people who don’t know him
• Shift’s blame away from himself




                                                    29
Set Off’s (Antecedents): Set Off’s or antecedents are the events that occur immediately before the target
behaviors, the majority of times.
• Criticism from adults
• Perceiving adults treating him like a “child”
• Getting in trouble with adults
• Yelling by adults
• Perceiving adults using sarcasm or discounting his ideas
• Adults saying bad things about his friends (even if true)

Responds Positively to:
• Limit setting by authority figures
• High expectations
• Adults following through with plans/promises
• Positive recognition from peers
• Calming down before attempting to problem-solve

Specific Hypothesis:
This is the statement that pulls the information together in a way that describes why Timmy is engaging in
the target behaviors. It is the basis for developing specific recommendations or a Positive Behavior Support
Plan.

When Timmy or others he cares about are handled by adults in a way that causes him to feel put-down, he
will avoid that class and/or behave disrespectfully to the teacher, in order to communicate his upset to the
teacher.

When Timmy doesn’t understand the work, he will avoid asking for help, in order to avoid feeling dumb.
This causes him to fall further behind, which then causes him to avoid attending those classes, which causes
him to not understand the work. And the cycle continues.

Team Members:
Troubled Timmy                        Special Ed. Case Manager                     Metal Shop teacher
Timmy’s parents                       Juvenile Dept Probation Officer              Resource Rm teacher
School counselor                      School Administrator                         ESD Behavior Specialist




                                                      30
                          Behavior Support Plan Sample

Student Name: Troubled Timmy                        Grade: 10th                   Date: 01/01/01

1. Hypothesis: When Timmy becomes frustrated or angry, he is less able and less willing to do school
   work. He avoids asking for help, in order to avoid feeling dumb. This causes him to fall further behind,
   which then causes him to avoid attending those classes, which causes him to not understand the work.

2. Desired Behaviors:
   • Arrives to all classes on time
   • Manages anger and frustration
   • Asks for help with his work, before getting frustrated
   • Seeks out and completes missing assignments

3. Strategies:                      Action                              Who
   A. School (Consider instruction, curriculum, environment, routines)
   • Maintain and follow through with high expectations, limit setting and promises made      Staff
   • Use calming strategies when frustrated or angry, and before problem-solving              Timmy
   • Provide in-class time-outs to calm down                                           Staff & Timmy
   • Monitor grades and develop & use plans to bring grades up to a “C”       Timmy & Spec. Ed. teacher
   • Timmy can go to Resource Rm, with work, to work independently Staff, Timmy and Sp. Ed. teacher
   B. Home
   • Review Daily Parent Report with Timmy                                             Mom & Timmy
   C. Agency
   • Coordinate efforts with the Juvenile Dept.                            Spec. Ed. Teacher & Juv.
      Dept.
   • Develop additional calming strategies, if needed                          Timmy & Beh. Specialist

4. Procedures for Managing Inappropriate Behavior:
   • Step One: Direct Timmy to use an in-class time-out to calm down, after he lets teacher know. Check
                       in with Timmy in about 10 minutes, allowing more time, if needed.
   • Step Two: Allow Timmy to go to Resource Room or the counseling office to prevent
                behavior from escalating. Assist Timmy in filling out his Problem-Solving form.
   • Step Three: If behavior requires disciplinary action, send to Detention Room

5. Measuring Plan’s Effectiveness:
   • Tracking the Daily Parent Reports
   • Every other week Progress Reports

6. Safety Support Plan: (Not necessary at this time)




                             Timmy’s Problem-Solving Form on Other Side

                                                    31
                                   Timmy’s Problem Solving Form
1. How am I feeling? [Circle the word(s) that best fit]       Defeated   Overwhelmed     Sad

Tired      Frustrated     Confused       Stupid       Angry      Upset   Hopeless   Scared

2. The reason I felt I needed to leave class? [Check off the phase that best fits]
      I don’t understand the directions of what’s expected for this assignment.
      I don’t understand how to do the assignment.
      I’m having trouble with some students.
      I need a break from that class.
      I don’t believe I’ll finish the assignment on time.
      I’m in trouble and don’t want to say something that gets me in more trouble.
      ______________________________________________________________________
                                       (add your own)

3.   What do I need to change before I’m ready to return to class?




4. I have solved my problem and am ready to return to class. ________________________________
                                                                       (Date and Time)
_________________________________________                 __________________________________
              (Timmy’s Signature)                                      (Staff Signature)


                                   Timmy’s Problem Solving Form
1. How am I feeling? [Circle the word(s) that best fit]       Defeated   Overwhelmed     Sad

Tired      Frustrated     Confused       Stupid       Angry      Upset   Hopeless   Scared

2. The reason I felt I needed to leave class? [Check off the phase that best fits]
      I don’t understand the directions of what’s expected for this assignment.
      I don’t understand how to do the assignment.
      I’m having trouble with some students.
      I need a break from that class.
      I don’t believe I’ll finish the assignment on time.
      I’m in trouble and don’t want to say something that gets me in more trouble.
      ______________________________________________________________________
                                       (add your own)
3. What do I need to change before I’m ready to return to class?
_________________________________________________________________


4. I have solved my problem and am ready to return to class. ________________________________
                                                                       (Date and Time)
_________________________________________                 __________________________________
              (Timmy’s Signature)                                      (Staff Signature)
                                                      32
Every Other Week Progress Report: Date ______________ Student:
Teacher ____________________ Class ____________ Period _____
Please return to Anne Johnson by Friday.

Circle the current grade:                            A      B      C      D      F

Responsibility for classwork:                                    Comments
4- all assignments in                                ______________________________________
3- most assignments in                               ______________________________________
2- many assignments missing                          ______________________________________
1- no assignments in                                 ______________________________________

Attitude in class:
4- excellent, focused & on task                      ______________________________________
3- good, needed prompts, but returned to task        ______________________________________
2- fair, not productive but remained in class        ______________________________________
1- poor, disruptive; removed from class              ______________________________________________

Comments:




______________________________________________________________________________
Every Other Week Progress Report: Date ______________ Student:
Teacher ____________________ Class ____________ Period _____
Please return to Anne Johnson by Friday.

Circle the current grade:                            A      B      C      D      F

Responsibility for classwork:                                    Comments
4- all assignments in                                ______________________________________
3- most assignments in                               ______________________________________
2- many assignments missing                          ______________________________________
1- no assignments in                                 ______________________________________

Attitude in class:
4- excellent, focused & on task                      ______________________________________
3- good, needed prompts, but returned to task        ______________________________________
2- fair, not productive but remained in class        ______________________________________
1- poor, disruptive; removed from class              ______________________________________

Comments:




                                                33
Daily parent report for Student              Date_____________ (circle A day B day)

Student will take this home each day and his parents have set up incentives and consequences. Please
contact his mother, Mom, immediately if you have concerns. Home phone is
 451-XXXX and her email is email.com

Period 1 (A: App Comm) 2 (B: Am Studies SS)                              Teacher’s Initial

Arrived on time to class                           yes            no
Respectful in class                                yes            no
Cooperative in working on class work               yes            no
Needs to finish today’s assignment at home         yes            no
Missing assignments                                yes            no     ______________

Comments _________________________________________________________________
________________________________________________________________
Period 3 (A: Science) 4 (B: Am Studies LA)

Arrived on time to class                           yes            no
Respectful in class                                yes            no
Cooperative in working on class work               yes            no
Needs to finish today’s assignment at home         yes            no
Missing assignments                                yes            no     ______________

Comments _________________________________________________________________
________________________________________________________________
Period 5 (A: Guitar) 6 (B: Pre Algebra)

Arrived on time to class                           yes            no
Respectful in class                                yes            no
Cooperative in working on class work               yes            no
Needs to finish today’s assignment at home         yes            no
Missing assignments                                yes            no     ______________

Comments _________________________________________________________________
________________________________________________________________
Period 7 (Intro FACS) 8 (B: Study Skills)

Arrived on time to class                           yes            no
Respectful in class                                yes            no
Cooperative in working on class work               yes            no
Needs to finish today’s assignment at home         yes            no
Missing assignments                                yes            no     ______________

Comments _________________________________________________________________
________________________________________________________________


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