All questions and response options in this form are copyrighted. Please direct questions about the use of this form to egraybill1@gsu.edu

This questionnaire helps family members, teachers and related services personnel to develop a plan of action for a child's frequent behavior problems. Part 1 asks about the child’s progress in terms of strategies that have been previously implemented and Response to Intervention. Part 2 asks a series of questions that help to describe the child in positive terms, and also help us to understand why the child continues to engage in the behavior. Part 3 asks about ways to prevent the behavior from occurring. It also helps to pinpoint the skills the child needs to learn to replace the problem in the long run. The last page provides a format for a one-page plan that can be used as an overview of the positive behavior support plan.

* 1. Please list the child's initials:

* 2. Is the child receiving special education services?

* 3. What is your first name or initials?

* 4. Is the child male or female?

* 5. What is the child's grade?

* 6. Has the child ever repeated a grade?

* 7. Please select the category that most appropriately describes you.

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