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Student Behavior Tracking Form (Tier 1)
Please complete for each incident of misbehavior to track patterns.
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* Indicates required question
Student Name
*
Your answer
Current Grade
Choose
PlayGroup
Nursery
LKG
UKG
1st
2nd
3rd
4th
5th
Name of the reporting teacher/staff
*
Jyotish Khanna
Himani
Neetu
Bharti
Babita
Priyanka
Santosh
Preeti
Mamta
Noorjahan
Sheetal
Rajnesh
Ritu
Other:
Date & Time
MM
/
DD
/
YYYY
Period No
0
1
2
3
4
5
6
7
8
Clear selection
Period of
Your answer
What happened (In short)
Your answer
Antecedent
*
What occurred just prior to the misbehavior? Check all that apply.
Unknown
Adult request
Asked to complete work/get on task
Asked to wait
Changes in schedule or routine
Did NOT want attention from adult
Did NOT want attention from peer
Difficult task
In a non-structured setting
Instruction from adult
Loss of privilege
Loud environment
New task or activity
Preferred activity interrupted
Told "no"
Transition
Wanted a preferred activity
Wanted attention from peer
Wanted attention from adult
Teacher teaching something
Other:
Required
Behavior
*
Describe the type of misbehavior.
Biting
Defiant
Destroying property
Disrespectful
Disruptive
Hitting others
Inappropriate language
Kicking
Refusal
Running away
Self-injury
Scratching
Screaming/Yelling
Spitting
Threats/verbal aggression
Whining/crying
Withdrawal/shutting down
Playing with Objects
Other:
Required
What was the impact (In short)
Your answer
Who other were involved
Your answer
Consequence (Action Taken)
*
Describe the action taken as a result of the misbehavior.
Called for assistance
Called parent
Given alternate activity
Ignored problem behavior
Isolated within classroom
Loss of privilege
Negative peer attention/laughter
Other students' positive behavior rewarded
Physical assist
Redirected
Removed from activity
Repeated request
Time-out
Used proximity control
Verbal reprimand
Marked -1 in AFL Record
Slap/ Handraise
Removed from class
Changed sitting/standing position
Other:
Required
Student's "payoff"
*
What does the student gain, avoid, or escape?
Gains teacher/adult attention
Gains peer attention/acceptance
Gains desired items
Gains preferred activities/privileges
Gains control over others or situations
Gains sensory stimulation
Avoids or escapes teacher/adult attention
Avoids or escapes peer attention
Avoids or escapes non-preferred activity
Avoids or escapes Instructional task (difficult, boring, repetitive, etc.)
Avoids or escapes non-preferred setting
Avoids or escapes non-preferred social interaction
Avoids or escapes a transition
Avoids or escapes aversive physical sensations
Avoids or escapes sensory stimulation
Other:
Required
Positive behavior that student displayed
Your answer
Severity
Ignorable
1
2
3
4
5
Attention Required
Clear selection
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