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l.r¡tton ci tng¡¡g¡¡.

naooenlng lmrrgolðtery onor lo tne student's Sroolem
oenavror {3nteceoent):

jrti ¡r¡urênt,.vrtn célr

_

i r¡de:

\

memoers tnvolved:

h¡t',vas

_-

lrrll¡r''l'

lncident Report Oocurhent and Seclusion ïime-Out
Log

t

I

ll¡trl

rçs

u-ro.3 \'.

'"1r lo rBstrllnt or sÊcluslon, ¡le3se oescrtoe
tþe oe-escalat¡on strltegtes that..vere ¡ttemoled by slarf:,
râón!.¡ t.'.:renr:!r (
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r¡ nôt too"( olace

lit¿r tlme Ou( wa5

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COmplete:

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li¡Jentlllnsr(ionedtoSuret¡ctlvrlvlnðãrlv.tewofksorcr
ce¡itvrof
,:en! Jncl rt¡ft ¿rgåged,n ¡ rilv¡¡(e ccñ'/el!¡tion åcoul lhe

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)rotnq to,-; cutr?nt t3A, ¡/nåt

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trÊ nvoothest¿ed funcllon of

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0ðte of Documentatlon:

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La'll¡¡ l. l¡t¡ttl¡;f

(iÐ

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lncldent Report Document and Secluslon Tlm

Studen

Bulldlng:

Date of lncident:

K.ô.{- ts

Grade:

Trmeo¡ncrdenr

tOl

,l'1

- I[:t(

oura¡onorrncrdent:é8

frrrn

Team membert

What was happening imm

.:

fight/argumenr with

nf s problem behavlor (antecedent):

/

pecr

.

3ElÈ*:b S\ J ï
Student was expected to tranlitlon *
Teachcr wåt anendlnt to otheru

,,uorn, was gtvrn a rark (whar klnd of task?

item

student was denied prefcrred ¡ctlvlty or

-

'

Student wa¡ told to move to ¡nother locatlon
-5tudentwa¡askedtowalt-5tudentwarpromptedtousespeclflcleplacemcntbehavlor(whlchone?-J

_

Student war glven one.on.onr ãttenilon

Othe

Prlor to restralnt or seclusfon, please descrlbe the de-escalatlon strategies that were attempted by staff:

.
_

-îffi

,m'vc¡ud' ence'+.;:":ä,,,*.î:::ïä::":"^#Ïffi

prompttng use of rlpl¡cement

behavlor

;'r'rc"d'wn

othe

Student non-oggresslye behavior prior to restralnt or seclus¡oni

\

'F\,"-

ù¡a

Student aggressivc behavior prlor to restralnt or seclusion:

t\

\

Student oggresslve behavlor durine restrðint or secluslon:

\6 cxr.'
Time
u

out:

Eeglnntng

tln

e

n¿lns trmc:

\[ I I S

I lf duratlon exceed¡ 50 mlnute¡
-

need parent approval, ¡f parent ls

navailable, need adminlttrator approval (document ilme/approvalt:

Physical

rostraint:

_

r¡o

,/ í",

.

/

,n o,"ns

conrrot

poltuon /r"r^controt po¡trton ,(

Beslnntnttime,

ì0,

tJ.

Endtngume:

Tranrpon Por¡tion

llì53

l-

Concerns, de¡crlbel

5¡gnature:

nme:

tl:?Ð^,rn

 ,0e'crlbcotherln uriestoother¡tudent¡,statfand/orpropertYdamagc:

Describe what took place after time out
StuCent rettoråd the

was complete:

envtronment

stu dent frturned to work

Student trant¡tlontd to qultt actlvlry ln a prlvate work rpacc
the behavlor
studênt ¡nd ilatf engaged ln e prlvate convErsatlon about

ta¡k

.-

5tu dent lEturned to work with th€ group

,

5ta

Studrnt rêtulned to gen. ed. tettlnt

-

ff
S

met lnformally a3 ¡ teðm to revlew cuf rent lntsfventlon ¡trateglet

taff w¡il meet formelly ¡r

a

team to revicw FBA/SIP (Mectlng

date/tlme:

-l

Other:

of.thls behavior?
According to the current FBA, what is the hypotheslzed function
the

-l_

place' :ee above to documcntl
cufrent FBA doet not addre¡s thlr partlcular behavlor (meetlng mu¡t take

This behavlor l¡ maint¡lnbi by acce$ to adult

attentlon

fhlr behavlor l! malntalned

bY

.

¡ccers to peer a$entlon

Thl5 behavior is malntalncd by escapc from loclal lnterastlon

]

t/

f hls beh¡vlor lr malntalned

rn,,

behavtor

by ercape from un.preferred ta¡ks or ¡ctlvitlet

ir malntalne d by acce¡¡ to preferred lt€mt/¡ctlv¡tle¡

f hls beh¡vior lr malntaln€d

bY

åutometlc relnforcement

.Does this hypothesls match the ABC of thls lncldent?

,/

_ t/
qf

ye5, our intervcn¡on was approprlatr end ln¡tructlonal/lnterventlon stratt5ies will staY the same

,rr, n*.r.,

team wlll revlew the rerponse plan'
our lnterventton may have rctnforced thê negallve behàvtor, The

be
collected for 5 days and a meetlng to rcvlew the FBA will
No, rhe hypothasir doe¡ not 58em to match thlf lncldcnt. A8C data will be
scheduled lplea¡e document tlme ¡nd date abovel

Whåt is the deslred replacement behavlor?
ned instruction are Prov

, How manY minutes of specia

for teaching

cement behavior on this student's

Mlnute¡ and rerulce'Providcr
fhe team will need to meet to dlscuss addln¡ mlnute¡ of servlce tlme to teach thll

Parent/Guardi an contact: oate:

,,n'.årñ-

mcnt behavlor

Mathod of contac
Admlnlstrðtor

Repon complettd by:
A

wiltten copy of thr repon mutt bc pottm¡,krd to the Pårrnt/8u¡rdl¡n(¡l

d¡V¡

Servlcc¡ Centcr
Send copler of rcpon tot P¡rcnt, Student Cumul¡tlve folder rnd Educatlon

,$þ

¡ncldcnt.

IEP?

 '¡¡:

o

ê

or ùocurrln?oflon:

'.#l lo\v\ (:t.tY
tf
I

ent Re port 0ocument and Secluslon
Time-Out Log

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jri,'lrit¡iftn(
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 )ote or Documenrar¡on,

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l()W¿\

R- 25-

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'{ ilixtt t[\l¡ta.r

lncldent Re port Document and Secluslon
Tlme.Out

Ð
Sludent:

Grade:

f ¡te oi rncrde nr,

leam members

8- 1ß,

;;fie ol lnctdent:

..

. ght/argument
wrth

the student,s

peer

_

:62

rvas ðsked

lem behavlor (antecedent):

Student rva! gtven a tajk {rvhå¡

:rr¿"nt',vas denrrd orefe'ed ¡cavrty or ¡rem
'5tudent

0uratron of lncldenr:

involved

'.Vhat r,vas happening imme

_
t/

l'. ht\

tind of ta¡k?

student rra¡ eroected to tran¡rrron

leacher w¡¡ ðrtenotng to orhe13

ituden¡ rvas -prompted to use ¡pectllc reptacement
behavror (which one?

to $,ðtt

-itudent wer told to move to another
- locatron

-_

itudent wðt gtv!n one.on-one attent¡on tdercí

Prior to restraínt or seclusion, please descnbe the
de-escalation strategies that were aftempted
by staff:

@7'".:-i.;.::;.,o..^..'-;:ä".,,;;.:.::;Ï"]::,#;:;:ï'forcooldown
r:rornplrn¡ use of replacement behavror

Student
non-oggressive behavior prior to restraint
or seclusion

5

be

tor

to restraint or

\i

3

Student oggressive behavior durins restraínt or
seclusion:

Time

outt

3egrnnrng

,,''n",

ltÌ9

E"¡,ngt,re;

ì:t+g

'¡,ravollable, need admt nr¡rr¿tor approval (documen¡
ttm€/approvatl

Physícal

restraint:

.- 'lo V ,r,

chrrdren's conrror

€þ

used:
-

/t, n¡e-

r

¡o

posrtron

concerns

descrrbe:

-'ioncerns,

L:lÐ.,- heinrrìn15

t€3

!

Enatu/a:

rv\^

need parent acprovå1, ,f parcnt r!

ream contror po3¡tron

geginning r,..,
- I : t*,3

rrrY¡rL¿r r€!ttârñt
I
was
*:,/aluðtton,
" " 'r f' chv¡lc¡l

' 'f iuratrqn exceeCs 50 mlnutes -

endins r,ri"!r

I'an!port Pc5,tion

l, tlLl

l5-

 -.¿scflþe

lnlunei to cthef ¡tudÊnts'

orher

Descrrbe what

5t¡f ðnd/of pfooefw

took place after time out was complete:
quret act¡vrtv tn a privôte work rgace
Student lransrnoned to

5Èudent leltoleo tne envlronment

./
V

t,.u

!c lvork

-i,iUdent,Êtulred

5t¡ff rr¡t 1;¡lr¡:lV

.l lh

¡5

oehavlor
gtuocnt ¡nd staff engaged ln a pnvate coñver¡etlon abouttne

-

work tatl(
rrlurned to-,¡.^.1

student

domage:

wrih:lt

group

StJdent raturneo

ü

lo 3en' ed' settlng

Stlele!¡le5
¡:eam t3 fevlÈw ct¡rrent rnten'ent:on

er:

hvpotheslued funcllon of this behavior?
to the current FBA, rvhat ls the

Àccordíng
e

cuff

.nt

F3A

documentl
(meetíng mu't t¡ke place, ¡ee aoove to
dce' nct sodf e5¡ lnls oaß¡cular behavlor

to 3dult
ceF¡vror t! matntlrned bv acceSg

fhìs

írom soclal
bÊhðvlor r¡ rn¡tntatned !V erc¡oe

-h I I

from un'prefertcd task¡ or ac(lvrtl€t
oehåviol ls Inðrnt¡lned bv e¡c¡pe

thlf

cenavtof

-:h

15

lnterrction

fn¡rnt¡lned by åcc!r¡ to pref¿rrcd ltem!/açtlvrttet

-hrs tehavror r5 malntalned

bV ðutomatrc

Does this hvpothesls match the

 /

ettentlon
iÌ^it behavlgr it marnlalned by rccess ro oeer

attention

-hrs

retnforcement

ABC of th¡s incident?

rtaythesame
,.ae5,ouf tnterventlon$raSappropllale¡ndlnstructionauintefventlon¡trategle5Wrll

o

wrll be
and a meettng to tevrew the FBA
Agc data rvrrl be collectcd for 5 davs
incident,
thr¡
match
to
not
seem
:r0, the hvpothesi¡ doe¡
tlme and date abovef
:cneouleO (pltðse document

,

ì¡/hat is the desired replacement behavior?
How manV minutes of
\.t;nutes and
.r

sP ecially

are

de

behavlor on this student's IEP?
d for teaching replacement

5eNlce Provlder

he t33m,rlll need

lo fnect to

Parent/Guardiancontact: Date:
?eport ccn'Pleted

bV: -

cli5cu53 eddinS

6"(

feplacement behavior
mrnutÊ! of senrice tlme to te¡ch thlt

-'"n"'

1'CÔ

l¡lethod of contact:
¡.JmrnlrtratOr slgnatule:

thrle d¡vs ol the lnodent'
to thc p¡rent/Buerdlðn1ll arthrn
å ¡/.rtten cogv of the repott mutt oe pottmarkcd
:tndcool!tolreportto:P¡rrn¡'studentcJmul¡llv€Íolder¿ndEduc¡nonServrcesCenter

ö

 l¡te

of Documentation:

¡()\V'\ (:l'¡Y

Ð

'{ ll.iit

t[\tßt¡.f

lncldent Report Document and Secluslon Tlme-Out

Ð
5tudent:

Buildíng:

r3re or iñcrdenr:

8

-

/ç'lX

iine

of

Grade:

tnc:den,,

2l D1

lur¡tron of

Incrdent: â-

 

Team members involved:

'.vhat lvas haopening immedi
' gnt/âr3umcnt

-v

to the stud ent's problem behavior (antecedent):

peer

lvrth

ttudent lvas grven ¡ t¡5k {whet k¡nd of task?

:tudent '¡'å¡ denlcd oreferred ¡ctlvrty- 0r

rlem

ltudenl

rvôr a¡kêd lo

itudcnt

wð¡ told to n-rove to anothcr locaïon

-

student lva¡ e¡oected to

trånrrüon

-

re¡cher wes ðrtendtnt to others

:tudent ivar prompted to use specrflc repracement
behavror (which

"vall

-

oncl

r

-

!tudent w¡r gñen one-on.onr ¡nentìon t,Je!cñbei

o-

Prior,to restraint or seclusion, please descnbe the de-escalation
strategles that were attempted by staff:
\'e

a/-Jiï,:'
_

¡

udience'

_ ;::; ï",,,;.î._::

r:romptrng uso of replacement

behavtot

ror coo dow n

;,

J :ï,'*; -"i;:;ï'

Othe

Student non'oggresslve behavior prior to restrarnt or
secrusion:

ç1
Student

prior to

I

nt or secluslon

Student oggressive behavior durinq restraint or seclusÍon:

Ui
fime

out:

3egrnnrng

,,^",

7,1,

enahgnn",Z:'

28. ' 'f

rñavåltable. need adrñrntstrator apDroval (documenr trme/a po¡ovall;

Physical

rêstraint:

_

rlo

/

Curat¡on excÊedt 50 mlnuter

,2;ltL,"lL
positron

,/!t+s Jrnuîrn,s

Control

3eginning

ton, f ghy¡rcal restralnt we¡ used:

*u'taruat

c:ncerns
-'lo

_

ñeed parent aoprova¡,,f parent ¡¡

ream controlpos,t,o

t,Ít€l

r:oncerns, descnbe:

:

-

ðnalurei

n

ãndrng t.me:

\¿/ r,rr\3;;lt:;l*t

lZ

 -.

¡nd/or prooÈrw o¡mâge
h el'nluf rei to olher ttuden(s' ¡taff
¿5crt b's o t

what took place ¡fter time out was complete:

be

Descil

e nt teltcre0 the envrf

s tu d
5

-,/
-{

,t.u

,-...^,e
e nt relurned to worl la¡K

tu d

!iu

dent 'elllred

ff

;¡3

:3

rr91 'fgrrrallY

qu'Èt ¡ctlvrtv rn
stuüent trantrqoned t0

onment

¡i ! :e¡m tt

pf

lvate work spage

prtv¡te converratlon about the oehavror
itudent and ¡t¡tf en¡¡gcd tn a

-

woft '¡/tln :le

¡

group

StuCent

t

reurned to gen' ed' ¡e(tlng

fevr:w curlent
- ¡nt!n'enΡon rtrategle¡

i tail',v'rl ne:t i:tmatly as a leâm to rlv'sw

Ê8Ai 3lP

'Ñleetlng

datertime:-)

rlthê l:

ÀccordinElothecurrentFBA,lvhatisthehvpothesizedfuncrionofthisbehavior?
h

e

c,Jf

f

3nt F3A úcet

nct addf

e53 lhls oarrlsular

'cchaviol (meetíng must take placc' teÊ ¿oove to documentl

-hltEeh¡vlofl¡rnalnrltncdbvaccerrtoaduttattentlon-ÍhitbËhavlol¡¡malntainedbYacce¡rtopeeràttentlon

-:
f

-¿

htS Eel,avtor r¡ rn¡tntåtned

OV

esc3!e frOm

SoCtal

lntelâctlon

-lrrs

from un'oreierred task¡ or actlvrtles
oeh¡v¡ort¡ marnt¡tned by esc¡pe

Thlr

Cenavtof

ltems/actlvrtlet
tt mðln(alnect bY âceÊst to preferred

rhrt leh¡vrol l! malntalned

Does this

,.1

by automattc rernforcement

incident?
hYpothesis match the ABC of th¡s

',.r,our

wrll stay the
inrtructio nal/¡nlenrenÛon strategrer
rnterventlon w¿!3 appfoprlaße and

plan'
wrll review the responte
rhe negattve behâvior, fhe team

dent.

icneduled

'uhat
How

same

(pleale documcnt tlme ¡nd date

ABC dðta wdl bo

S

rÊvi€w ¡he FBA wlll be
collectcd for 5 dav: ãnd a meetlng to

'bovel

is the desired replacement behavior?
IEP?
replacement behavior on th is student'5
struct¡on are provided for teaching

many minu¡es ot

.r:inUt€S and serulce PrOvlder

fh.

t€¡m wi,, nErd

to meer to discu¡s adding mrnutei of

Parent/Guardian Contact:
?egor! conPletect bv:

Dðte:

f-?6

r,^",

sen¡icE tlme to tÊ¡ch

h"OÖ

thrt replacernent behavior

Ìtethod of contactl

¡dminrstrator

5r

gnatuf e:

A¡/'lltencopVoftheleponmuttoepostm¡rledlotnepa¡rnt/i u¡ldl¡nt¡1.¡,llhlnthreedav¡ofthetncld!nl'
to'der ând Edug¡tron Serv'ce¡ Ce¡ter
j¿no coore¡ of r!9ort to: P¡r!nt' stud€nr Cumule(v:

@

 '¡r::

t

'ä*)

to\v,\.t-t.,,

rding:

T

-i.l m memoers
h,:t

.',

:rJcle:

s

" -? ci r-¡r

jr:,:r'rnfrr

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-._

:

xr(,.,

ce!,

,l-'¡8nt

¡ileo!c"v¡lt

-.j¡nl r¡i ::to
1

,.:!:!'l

l\r .\

onor to tne student,s oroolem ceh¡,¿ior
l¡ntecedentl:
'.v43 {rven

::'J':3rì: t/¡i :en'od !t3t'rliã rc!¡vltY- or ':f¡

.-

at

-'.f,ltlon :i t^ç,'an,'

Inr/olì/edl

rr¿as naooenrnç tmrrÊota

-X

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dent Report Docurn ent and Secluslon
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B/"shs

l()\Vr\ (ll'lY
Y Úritt

ItltI{l¡.t.

incident Report Oocur¡ent and
Seclusion lime-Out L og

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'-

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rrc'¡ent: 2 -tt 1

rn,¿ol,redi

nã0oenlng lmrreoiatelv onor to the student's
oroolem oenavror l¡ntecedentl:

j¡'i,'¡ri'J ].tnt,,v,(ilaeef

_.t_¡ent.,v¿,{rven¡t!thlìvnatínc,of?¡rí)

:L..:¡rt ,./¡t ren,?O c¡ertrr?ã

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o¡ :-.m

l-.:-'ñt'.¡rll¡51èttlo,,r.¡¡t .:'-'-.:lr¡

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lacn?f

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look olðce ltter tlme out "vas completÊ:
ii¡Jenttrlns'tloneotocui¿1 lct'vttyln'¡oilvlte

:r-.rdènti::t-:tlo'.F?e¡v'foñáeît

'vofksc¿¡ce

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.:ujentfrl!14 010.'ïor'((],1:]L.:ent]ndilan?¡gsge(l¡n!:r! ,,¡(econ'/ersåtlonJcout!Fee?t!'.1:cl
¡á' !eltlnl
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¡ ri -r, 'n':í¡¡r"1 Ji ¡ ::lm
. r.,r..,¡.,r¡ -e

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-':'/ ¿w iSAi 3t¡'ì"'l?f

lç\

,.ç (-*t rñ<-è

lrg;¡t3/!ì:r€:-;

oc.,.Jl

tne nvoolnesl¿ed functton of :hrs benaviorl
:ro¡f'rg ro trå currant F3A.,'vnat;s

'-:':'-"-:ñ1'aÅ'i':e¡rc!lloretSt'r:5:¡rilcL';rl:!n¡vlolrãe!(!rlfnus!:ðß¿plJC¿'!¿ê¡tovÈ!oJocuítenll
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tr¡stril¡.1

Report Document and Secluslon
Time-Out
5

ruden

3urlding:

: ¡te gt 'nçtce¡li

l'¡e

log

6rade

of tnc:Jent:

l¡fåttO¡t :l '.Crdent:

f¿¡m

memoers lnvolveo:

"vhat

''vas haopenlng immediately prior to the student's
problem behavior (an¡ecedent):
gnt/argpms¡¡ rv¡lh

.elr

,./rrurrn

!turJen! ''v¡¡ ren:ld qre'erred ¡cr:v¡rv

-

jt.,¡dent,.v¡t ¡¡k¿d io.¡r¿¡!

_-

!tudent ìr¡! told to

_

rr,!ove

lvas 3rven

or,têm

:

la¡k {wnar k,nd of rå5k? S

itldeñt

iì

¿lC};if {=-,- tt I t,rç,\'(

lvas e¡oec¡ec, to tranirr:on

-ercher w¿r ðrtenotng
ro others

;t,rJenf tvås -oromÞteC to use !pectrtc
replaccment oehavtot l$/ntch one,

_

-

to anotl.er toc¡tton

:tudenr w¡¡ gtven onr-on-one ¡lt€ntron
táe5c¡,be

,)ther:

o

Pri or t0 restraint or seclusion, please
descrtbe the de-escaration strategies
that were attempted by staff:
gircct lg cool down

,./r"ilrmrrr
;rorñpl¡nl

trf ,

rFen)

¡rea

gnonng (not provrdtng anentton
for esc¿l¡ted

use of reclacemen¡

benavror

beh¡vrorl

offered chorce¡ for cool down

/rrrrrrrn"n

Other:

Student
non-oggressive behavior prior to
restraint or seclusion:
Stud ent ogg

b i,rl)

behavior pilor t0 restra¡nt or seclusfon:

(tlt:

Student oggrcssive behavior durj0g restraínt
or secluslon:

líme

out:

r;"4 /alrå91e,

Physical

legrnn:ng r n

r: å, 2

re30 ¡cmrnrrtri¡tor agptov¡l

restraint:

_

.,l

f

t.i

tl.

i'Cing tr'rg:

o ccurnent

.*

a

n, n

(-,

L

' 'f Juratlon erceeC!

:,me/a ooro,ratJ

.r5 _

S0

1i¡Jtes

_

.eec oarent aogrcval,,f
i¡rent r¡

Fo!¡trcn leam Ccntrg! ¡65,;,9¡ ù..r, -.a.sco,¡
,1 t 11 ¿t
fl:;r'11,
""1 ^ 4,-(r
3:3,nn'n3 z n¿':x&f:

lh¡iJren,r C.:nt!,?l

,,,..,

zl å,uê!.c1, f ;,-v¡,cal 7e!:.¡r.1 wa5,,!:J:

ü

',o

-

CÇt

cz

:s

tcnc:r,,:¡, Jesc¡ ce;

. íîatJ'?

p,ts.í

c,1

 I

p:ccer(/
¡luÍ'e5!o ither liUCelit':ì¡l ¡rd';r
l¿SCrlCe o(ner

gescrlbe what

1¡mâgè:

r!'i l;

t/

comolete:
look place 3fter tirne out lvas

!tUdentlsslcfeolFeir.vtfonrnent..-stuJentlf¡nsltlonedtcqu¿tãcllVttV¡llapljvðtc.ÑofKloace
prrvatc ccnver'e.on eg'Ut tre
:tuoent änd rta'ent¡ged In r
nr returne' !c,ivgr[

_¿_stud,e
srucJer:t'elrireolt'r¿o¡\wrt:Ìir¡g'otp

;¡3tf
I

'r¡.rl

ñ"t

oenavror'

!35K

!t¡lentlelurneotS3cn'eJ'g¿lt'rg

t\teetlng
13'ev'ew i3Ai 3lP

i:trålr,7 at ¡

o

d¡te/tlf

e'

i

"?lm

!ner:
to the curlent FBA' what

¡ccording

rs

this behavlor?
the hvpothesi¿ed function of
lace, 3ee ¡oove to documeñtl

4é:necullrntiãAúcelnc!Ðódf!!5rn.scan¡cu arcehâvlollmeetingmuslt¡krp

V'

:

/

'l'

artent:on

.h

r

bv accet5 ¡o ¡dult
5 ceþ¡vror ri rnalntlrned

:h

i

from soctal intrractlon
s EêFðvlor r¡ m¡tnt¡rned Ev etcsoe

¡cçe¡¡ to paef atlen¡lon
r bêhavtor l! r¡alnt¡rncd bY

:hrt

from un'preíerred ¡¡sk¡ or ¡ctlvltle¡
celevlor lt mðlnt¡lned bV esc¡pc

ÌhlÉ

cenevlol r! rðrntalneo

ÞY

lccË¡¡ to orclerred rtemt/acttvtttet

-hi9

rernforccment
rehavlol It m¡lntalned bV ¡utomat:ç

Does this

of this incident?
hYpothesis match the ABC

8nd in¡tructtonal/intcrventlon
'rrr.ot¡r rnteryentlon w¡s ¡gpropll'te

,./

Strate gres wrll stav the seme

û

0lan'
fhe team w¡ll revtew theteÉpon31
rcrnforced the negatlvc b€havlor'
h¿ve
m¡Y
tntefvênrlon
ver, howevef ouf
the FBA wrll bc
for 5 dryr antl a rneetlng to review
AilC d¿¡a wrll be collected
ingdent'
thr¡
m¡tch
to
rerm
tþe hvpothc¡¡¡ do€s ñot

llo,

ume and dðte above)
rcneoule d (pleåle oosumtnt

'l/hat
How

behavior?
is the desired replacement
in struction are
manv minutes of speciallV designed

'.1¡nutes ano lervlct orovtder
íhÊ tåtrn

neecl

on thls student's IEP?
Ïor teaching replacement behavior

feplacemQFt beh¡vior
of ¡en¡tcc ttme to terch thr¡
!o fnee! to cìtcuss addtng mrnutes

"vrll

Parent/Guardian Contact:

-

ed

Dale:

Q,.?\
tJ L'
'-'

:,,".,

hfl1

'.'lethod of contactl
¡ Jmlnrstratcr 5rBn¡tu¡e:

?¿Fort cCrF!êtEã

þV

¡rr,ttenc¡oYof:hel!oonmu¡toe90!t'n¡r¡rdto!nepafent/gu¡fol¡nl¡l',, thintnrced¡vrolthrlnc.denl.
CJmul¡trve
:tno G?tlcr of reoorr to: P¡lEñl' 5r!¡!nt

FotdEr ¡nd Educ¡¡¡on

Srn cer Csrl¿r

ffi

 f¡te

9J

o

lncldent

Re port

5tudent:

(il'lY

{ ll¡hrl ltr\tßlr.f

Document and Secl uslon Tlme-Out
Lo

ldin

rrre oirncrde r,,

E'hl- 16 -

feam members

involved

Grade:

;:me oí tnctdent:

!urat¡on cf

'.t/hat r,vas happenlng immed iately prior
to the srude
¡

l()W¿\

peer

ght/a'rgumenilvrrh

/

s

,,ud.nr rras gtven

-

!tudent wa¡ d€nled oreferred ¡ctlvlty or

_

¡tudent wat atked

rrom

problem behavior (antecedent):
a

trr* î í I tl

tark lrvhat linO of

Student rvas expectcd to

-

ro lvatt

of Docuñentagon:

Studenr rvas prompted to use

tranr$on

leacher war attendtng to otherj

rpe.trc fepracemen¡ behavror
- (whrch

one?

r

-

3tudent wat told to move to another locâtion

-

itudent w¡r

given onc.on-ona anentron tdescrr

Other:
-

¿rlor to restraint or seclusion, please descrtbe the
de-escaratíon strategies that were attempted
by staff:

5etðtr.ri€r
ûZ

gnonng (not provrdlng ¡ttentton for
escalated

",:ï,":iaudrence)
prompttng use of reÞlacemcnt

-student non-oggressive

o¡recttocooldownarea

behavlor

orreredcho¡cesrorcoordown

behavrorf

-

l/

,ur/rn"n

Othen

behavior prior to restraint or seclusion:

Studèpt

to

ra

or seclusion:

Stude nt oggressive behavior duri.ns restraint
or seclusion:

(

Tíme out:

3egrnnrng

,,^",

l2ifu)

Ëndins.mei

J?l\¡

,¡navar¡able, need admrnr¡ tret0r approvat
{documenr trme/approval):

Physical

re¡traint:

_ ¡lo /

'¿t _

_ ' ¡f CuraÌron exceedr 50 rnlnutes - need oarent aoprov¿ ,

Chlldren'¡ Control

posltron

3eginning

@

'/åluatton' 'f ol'vs¡cal rêitrarnt rves usec:

ccncern!

-'ro

_

r'^",I2-'.

r:oncerns, d€'crbê:

-

leam Control posrtion

:'Enáture:

/-1

ãndingr;me;

/

lL\3

,f parent rr

,,rnrçorr position

 :¿

sc rr b

å

llarf ¡nd/or procgrw doma¡e:
o t h er'rtiune5 to cther etudentl'

Dascrrbe what took
Student

place sfter time out rvas complete:

r8ltoreo the

qulÈt actlvttv rn a prlv¡¡le'xolk !oace
ltudÊnt tlanSrlloned to

envrronfncnt

'/''....'..i}..vStudent¡ndlt¡ffenBagedlnaprlvatcconvelsatlonabouttheoehavlor
relurnÊo lo wor[ tall(
¡/sruo.nt

#

;iuctent'elur¡edlcwol\'Ñrlhtl'Egrou.p

it¡f f
S

r)

the

t

rn?t''rlsrnallv !3 ! :e3m
atf

rvrrl

relr ilrmallv

a9 a

tl

lnleruention rtÍategleg
lcvll:\r culrent
-5tulentretulneotoSen'ed'senllg

datel
te¡m lc rev Ew tSAlSlP lMe€tlnl

time:

,
)

I

.\ccordlng

to the current FBA' what

15

bv acce¡¡
h r 5 cehavror i3 nr¡rnt3rned

behavior?
the hvpotheslzed functlon of this

to adurt

attentron

Íï.i3 behevror

rc marntarned by ¡cces¡

to oeef åttentl'n

7-:necUrrrntÉ¡Adce'nctaddres!rhl'oaßculalEch¡viol(meetlngmu¡tt¡keplace,seeaoovetodocumentl
fhl3

irom ¡ocral rn¡eractlon
!Ênavlorls matntatned oV esc!p€

from un'preÍerred ta¡k¡ or actlvr¡¡e¡
oeh¡vlorri marnt¡lned bV elcape

-L:hrr

the
Does thls hYpothesis match

\

ABC of this incident?

ånd
'./Ê5, ouf rntclventlon was approprlate

wrll s¡av the s¡m€
lnstructional/inrenentton stratetie!

¡he re;ponsc olan'
bch avior. fhe te¡m wrll revlew
may havc rernforced the negattve
Yes, howevef gur interyenllon
the FBA wrll be
for 5 d¡Y¡ and a meettng to revlew
ABC d¿ta rvtll be collected
lncldent'
tht¡
match
to
,.to. rhe hypothesi¡ doc! not seern
above)
(plEa¡e document ttmr and date

o

icnectuled

,,Vhat is the desired replacement behavior?

IEP?
behavior on th¡s studen t's
provided for teaching replacement
are
instruction
ally designed
How manY minutes of sPeci

..1¡nuter and ienlce Provtder
mlnutes of :enrtce
f h9 te¡m will need to meÊt to dlssuet addlng

q-

hl¡ reolacement behavìor
ol contact:

Contac
P a re nt/Guardian
r 3lgnature:

?ecort ccfrÊfeted by:
A ¡/fitton copv of rhe rspor! muit

o! 9orltnsrtrd ro

'¡rthrn thre¡ dav¡ of the tncrdonl'

tducatlon SenrcÊ3 Centël
Slud€nt Cumula!¡'r: lo¡der and
:¿nd coller of report lo: P¡leñl'

@

 -'

¡t€ üt Oocu.neñt¡ttonl

'-**l l()\r,¡ ¡'¡'¡-¡

,,.:,Þ

.rf

t llt¡ll

tÍtttta.l!

lncident Report Oocument and Secluslon
ïfme_Out Lo

)
-ìtuden t:

:l:t

ìurldlnç:

g

ct lnçrcar!:

-i¡m

er

lr(

''

:'? ot

t

!r¡de:

rncrdenr 3'.

tZ -

3Ia

o_

-.

¿rlr:oñ or

rr{crdeñr:

I

6

,q, .. _

memoers rn,lol,¿ed
n;topenlng tmmediately pnof to the student's proolem 'oehavior
(¡ntecedentl:

"/h'3t "vå5
\,/ ' Jnt/¡r¡un':èn!

wrtn

6erf

:rlJent w¡r ltven , tark l,,vnrr krnd oi

i:'.cent w,!t 6enl?c o¡:irrred ¡cltvrty ct

_

,. :tu\..ent.,v¡td¡t(¡útr,,vårt
Ìtuuent

_

.,rðr

_

,(¿m

tStn? .

I

!lu\rent w¡t eroectect to t l¡n¡ttton

_;lu,Jenitv¿toromoteotousaloeglficreotacenrentcen¡vtortwnrcnonel

totd to rrrc,rl l0 Jnolt¡¡ ¡q6¡¡¡9¡

I:.:.:¿nt ,.r¡! qtvên tnÇ..tn-onE ttienrron r,relctrbe:

'1riÔr tQ restrJlnt or leclus¡on, olease ctescrlbe lhe ce.escalatron str¡tegres thal
',vere ¡,¡tempted by st¡'f:.
: e¡r I rårrror'/l ¡uülèncrl
i*t t t,mel
"-ìcrñ
-',r lct to cJor down rre¡
,_:rf:råo ,:norc* ror rcor
:orrn

þ
l-

'l v 2

-

J

-

-il'rn'?t ¡'l'iF?¡l
.'.rr-.rrirE

i',denI

.;Êorlfglno!trrovloltrl¡llBnttontor:rc¡lðted!€h¡vro¡
-

-

Jr¿,Jt ric,¡É:rnent

!en¡rJ¡or
-

non.ql'gresstve beh¡-vto( onor to restrðtnt
0r îecluston:

I

Q.r

:iut€fit

t1EÇt€SSttt€

.frdent

aqgrssstvg beha,rror rJurrfg restr3tnt or gecluston:

'irr¿6Lt¡;
,'l,ðrJGli!, fiiC

)

D*.

e

J:gr.rnrr¡,.,=", 3',2L
i^dirg !rr..e: 3:3O.
fOm,n îtt!ler rBCrlv¡t ItäC,J ;t.lerl:lm?/SOCttv¿tt

Ç¿twta',la[ ôe€.n
V

:\',,s¡calr?str¡rnr:

,,

r,

{

a,

J,¿n,,

,

\ì -:/l'',irt,:n, i:-,,!^:ll r.:!:'lntl

,,¿åi rr:i,J. {

,,rr::-i?rnl

_.'_2^

\âc

,f lu¡zt:cnr.rc::¡l :0 .ftrnula9 - ni€ r s¡r?nt

Ccr,t,?t?a:,t,rn - -:¡m l:r:,ll
llltnnrnl !¡rrt:

)

S-o.,,".

rJeh¡,¡ror ono! tO f:Stfatnt Or S:C US.On:

k

c

{<

--i,.¡./then

,.1:i:er.

llt¡

1,

t

ZSr-,'C Z :

3I t2

ô,

ors,tin

3...j:r¡r¡¡r.

coon^
9¡r:nt

¡Ocrcv¡t, ,i

3..ZL

,5

   ()cnÊl rnlurret to

re

¡lnti tludent!, it3f ¡nd/of

ñl A

prqcefw d¡m¡q€:

wnðt look olace siter tlme out rvas cbmplete:

tuL:ent rgtlorSo lh! envrronment

tucent

r?turnect ¡o

:tuLii!nt telulneg
'' ¡ ri

n:l

wofl

!O

'l!':ên! lnd lt¡ft

l3!K

rvorl wrrn ¡he

ltucent retu'neo ro len' tc' tenlnç

lroup

Strllellet
tntcr':"¡tlv ¡! r !:tm :o l:r'lèt ' current lnt¿n¿Ënllon

rùleellng
;t¡tl'rlrrt  ?eÊl icrm¡tlv 3! a t!¡m !o revretï iåArðlP

-

.ding to the current

s

FBA,

what l3 the hì/pothesi¿ed functton of this behavror?

(me€tlnl mu5l lak' plùg!' reÊ åÞov' fo ooçumentt
€ J,?nt É¡A JctS nog ¡dor!ç rnlf c¡nlcular c:navlor

,;ì:

-

ot(e/tlmc:-J

4r

ô¿

_

¡ngaged ln å pllv¡te cont.l€fsellon ¡Þout rhc oenavrol

-ï,!

cÈ^¡,^or rt m¡rn(Ðrnco bv,¡c::¡r to ¡ctt¡tt

attentlon

Y

'hlt ce¡avlol

13

m¡lnl¡lneÚ bv Jccets lo p€el ¡ltenlßn

åtcloc lrom ¡octol lntlractlon

-'.i5 :enåvlor It mãlntalned

bv

''l' t iaFðvlql ll ¡rðlnt¡lneo

(¡¡K¡ or
ov Êtc¡oe lfom un'pf!ÎËrf?ct

-t'ìrt c¿a¡'¡'Jl rf lrt'.ñt¡lneo

oY

-::,s :êFtvror ti m'lrn!¡ln€ct

ov ¡u(offtåßlc

rni5 h,/ootheslt match ¡he

¡cllvltlêl

Jc¿êli lo or"rlfeã lte'nt,,ctlt¿rllet

ABC

¡:tnfo¡cemlnt

of this inctdentl

.:r. .:rrr ,r(eftenlron wi¡¡ ¡oorEgrla¡r

'no

ltr!truc!:onal/lnlen'entlon rtr¡leglet ''vrll ¡l¡v llre samt!

_/'ls,.c.'vÊyer,'U'.ñtei,enl on'f.¡vn¡vef€ln'orceál .en?E'llvaoeñðv o'.í''!''reðmlvtllla.¿rèw!helesoon¡eotan'
're
..o,,,!.¿rÌ,rcu!ne5'oûå¡,aotleam¡o,r:ùlcn¡nt9tnc;ient. ¡åcJJiJr.,rll',.:É:Jl:a¿llcl':ri'J¡vr¡nl'-E:!'r'gtf '?'/'t'¡/r¡"?Fla'¡¡ll
oureú I Ole¡le 'lccu]1 9n! tlrF€ ¡nd calê ðoovil

,¡t ts the oe5lred reolacement bena'¿¡or?

\ôr¿4 Y-

ior teacningraplacernent Eeh3vloron (hr9 stur'Jent's rÉ-P)
vfn Jn,/ rnrnu!Ê' Oi:oecrally,JesrSned ¡ngtructron are orovroed
rlil3

ãnct !alvlcë cfov t!eÍ

-. e :t¡m .,¿rl r¡!:ct ?o r-ti( iã t;5C,JSt ¡údtnl

ln-rGu.rd,an Contact: r¡te:

m:nu!3s

tí !?ru't! ?'rrrr ?o :e¡ch

-""e: lO'ÔOô-

!h't f'olac?lr1?r!t 3en¡vror

"r¿t'crtof

icn¡¡ct:

r,jmrnrStrtt0t tr¡n:tur!

:?cott::¡cril?cl !v:
¡

,rr,tian r:0,/ ol

'F: rltot! r¡uit tr acttfftrhtc !o tn! '¡renl.' lu¿fol¿nltl 'ït

l-.t,t1¡2s,¿lttl,alAll:.r:,1.ânl,!¡'.¡'jentl"rn'¡l¿¡¡¿*f?':rrrndãC'JC¡!¡On!¡l'rtCct{et"'r

 o

.'r,rot'ucumen¡¡r

I , lS

,r^rQ

'.Ël l()\v,\ (:l'¡.1
H

,@

g lh'lrl lllltta't.

lncldent Seport 0

!tud en t

llts

f

GrEclel

\\ ', OS -J,',ål

_

.

_

Jlruent w¡t

2b

lJr¡lran oi lncrdcnt;

tl .i^¡

I

ì¿:

lnvolved

håt was nðppenlng

rmm

e

ihf/trlumtnt',vttn oEtt

'ludrnl

nB;

'' rr oírncrdg¡ri

o¡ lncroonti

'!':¡m memoers
,'i

Tlm+Out log

_

studenÍr problem behavior (lntecedent!:

Jl:rlent Wlr

ktnd

ol

o?nlrct orelêf rgd ¡c$vtlv gt,rÊm

',v¡t at¡[s(t

llr'r¡rt

¡

¡tn

i¡udenr wi¡r oromorrrt to uta torcrrìc rêorðclmrnt
lcn¡vror r,'nrcn

on!,

- toç¡tton
lctc to rnorr to inolnãr

_'(ulrrnl,.vð¡

ll'¡:¡nl',e¡f

llvÊn cnt.Ðn.Or,:E !liEn(ton lr¡€¡Crtbc:

,:)'èri
-

,ffi

'trior to res(r¡lnt or ¡eclu¡ton, Fl€ase descrtbe the de-escaratron ttrðregres that were artempted by:taifl.

ir)gm:'!Ðrr.tm'Vn¡Ur¡tèn.Èl j¿la¡lmer _
)rrcCtlOCool d.wn¿lt¡
:il 'rrn'lt rrl, lñånl
¿;raîu.g lnot orovrdrng ¡(tênlron for ¡¡catatEd behðvrorr

);
V

.:r:trtlr¡l

Jre ot

r:ct¡úrmfn(

crnð'/ror

,::i.:er:

e

nt

ûaqre

rÀ
i¡udent

îime
,

)

seclusion:

tlte beh,lvlor g4gf ro restr¡int o¡ secluslonl

oqgressve beha'¡ior dVrinq restr¡lnr or Seclusion:

outl

?¿rnnrnl,,"t.

ll i /3

:"d

ng

(rrrr.:

/l

:

'l'/år,;tcIc, rtJá icmrn,!trtl,:t ¡00rovðt l¡ocumcnl
::n,!r/roprov¡tf
:h,,u

@

s

JO,ñn

-;,ri,/then

jtudent non.\Tîqrgsîlve oeh0vro¡ prior to reslratnt-or

i tuÉ

,jÌ{trrdCn'tclrloriÖOl

sical

reitr.ilnl:

_.i.,

!*,'

o,

å

I

''l

Jur¡t¡on åxce:dt

oî r cc.nr:r ¡o!rr, :n
i rgrnnrng

:'/l'r., ¡ttl:n, .r.:-,r¡ ,;ll ,!tÌt¡iltt.,,r¡t

r.giJ: Vtr:tn:âfni

m,nur:s

-ntrd

?¿renl ¡ooro,/¡t,,i

': lm C¡ntnl 5o¡.1on
_

_

trlrl .

I1

rllltetnf, drlcr Cr

-

5,J

c¡r:nr

¡

:

t'lf',i1'

i

13.-

in1,¡{

rrmr:

),1

-,lr¡part prr

I 13

:cr

 ¡

I () rnel

oe

rnlulrÈ9

I

u rjËn( te(ulned

reurned to gen' e'1':ewtng

to'¡'oll 3,

ri rr:l .ntorÍ'3ll'/ ¿! ¡ i:am io r:t'lèw
rreet iolrnalþ'

it¡tí

¡i

gulét ¡cllvtlv rn ¡ pr¡vote worl( ¡pace

prlvðte çon"'Êfsstlon ¡boutthe ocnavlor
il"lcent ¡nd ttarf ?ngagÊd ln t

r!rJcê¡t p¡urneo ro trrorl(rt3rl(

'..¡

À

.17.'tr,r¡rnt lr¡nsrtloned to

,nran,

tudent lertor€ct thg !nvtrt

jt

.lt"ø

lvas complete:
whal took olace ¡fter time out

 

{

C'

ìJ/ 4..

dAmaqc:
to gther rludent!' rlÛrf ¡nrJ/or ofccerî/

ð !ei¡rn

-iludent

currgnt lnigfl:ntlon

¡c rEi'rew

FSAi AIP

¡¡rlletlel

!Ñ'lectlnl

date/tlmel.-l

"v¡rr

,0i.,*tothecurren(FBA'lt¿natisthehYpotnesizedfuncttonofthisbehavror?
r':e çurrant É¡A ,Jae'norldoreJs(nlfg3nlcul¡¡rcenav oflrñe€llnÍmustlakëplJce.ieeaoove(ooocumçn¡}
'l'r¡ cenav¡ol ls '1:tn!ðlneo bv åccelr lg uëer ¡tten 0cn
-¡i,É
tl malntðlneo bv ¡cÊ955 to ¡oult ¡t!!n(lon
cèña,rror

-r1tt !:þitvror

15

lnteractlon
matntatn€ó bv esc¡oe írom ¡ocr¡l

r:n'prrtarfeo tarKS Or ¡ctlvttlet
'' r ' ç Betovtol t¡ rnð¡n(atned bY Ësc¡oa irgm

/
-

-

",u

es

this

Qv

6d

C\¡s¡raoon

,t
v

this incident I
h'¿gothests maItch the ABC ol

¡'J..' .{lìvgg.le5li'JtlÈ¡lro!lê€fflio¡.,.,¡tcnlnlilnc:can('

ñ,"o

Cz¿'r

¡utofñåtlc t¿rniorçemen¡

rtr¡ßegler
"vrll
r*r, .t!t.¡terrrentron wå¡ ¡oprcpll¡tè ¡no lnStructlonðl/lnten'enllon

V

.

IO OfÊtillred ltern!/¡ctt'¿ltle!
caÁ¡'/lof I5 må'nt¡lneo ov ¡cce!5

'iìr5 aen¡v'ol tt mùlnt¡lneo

-

T,,€

I

ttav lne ¡¡rre

¡-eer.ñt11
Aåc.:ùi¡,...{;l !e.¡llÈ.l.clc¡5Jr.¿s¡n1

)
'?.,. .rrle;lAwrllFe

r:llç ¡oovel
urf,¡te':ocufnent llf'. e ånd

hJt ts the desrred reolacement behat'ltor?

beh¡vtor on thrs sludent'¡ tÉP2
are provlded for teachlng replðcement
truction
tns
destgned
1,¡ 1rìilrìv ¡l¡¡t.ltË5 of spectatlV
,r':lri:5 ilno lzlvtça 'llol'tiel

UA.
:

ren¡/

-.e:i],ftr¡rll .?:dlo!119..t!o::5qU!5¡üd n8m nu!33oÍ¡en¡rçe! lne â:e¡chlh'f
G

r¿olacemen¡!enâv ol

uardian Ccntact:
jdmrnl!trllor tlln:ture:

:

rco rt !:ß3'{ted b'/i
ì ¡r,G€n

¿:9,i'

trE tJrenl,'lu¿ltl¡nl ¡l
el:Fl rtãcrt ñtlit':f oâttñ¡treó lc

¡
cnt f . r¡
r¿,,1 ccate¡ oi.ecorr :o: 1r rñt. iru,J

¡r¡

tv¿

íc

¿qt 'tn'l irjr¡c¡t ¡ ¡ J tt"r¿Éi c¿ r iel

,''ry
'/

 e¡te or Documenr¡rron,

I r;t I t 3

¡()w\ (:t'tY

Þ

{r

s ltr¡rt ttt\lßn.tl

ent Report Docurnent and Seclu slon Time-Out Log
Student

ilding

'l¡te oi lnqdentt

iime of

leam members

Grade:

I

0uratlon of lnodent:

J) r}{{/t

involved:

o

',Vhat was happening immediately prior to the stu ent's problem
behavior (antecedent):
I'ght,/argument nrrh peer

_

itudent

-(,ro.n,
wat dented preíerred ¡rcttvtly or ttem

student wat asked lo

-

walt

rvas grven a tark lrvhar kind of task?

_

_(¡)f-d$

Student rvas expected to tr¡¡nst$on

@

o\ ffi"ï"

?d(,

T

feacher wðr ¿ttendlng to o¡hers

Student was prompted lo use specrfrc repracement
behavror (which one?

-

5tudent was told to move to another
- location

-

5tudent w¿s grven one.on-one anentton ldescri

o-

Prioi'to restraint or seclusion, please describe the de-escalation
strategies that were attempted by staff:
floom cleðr lremove audiencel

@

let

É

limits (if,

rroro,rng

thenf

-L
é

set ð

trmer

Oirect to cool down

'gnorrng (not provrdlng ¡ttention for escalated behavror 

Time

¡

out:

3egrnning
Endlng timel
navallable, need ¡dmrnr¡trator approval
ldocument tlme/approvall;

ta'.
¡ro

reStraint:

Evalu¡rron, rf phv¡rcar restrarnt

@

Firrt/then

@4,K* ö

*..57

restraint or seclusion:

b

Physical

_

o'ru' r prlor to restraint or seclusion

Student agqressive behavior orlor to restraint or secluslon:

en

offered cholces for cool down

ure of repÞcement behavlor

Student n on-dggre ssive

s

area

'

lf duratlon exceeds 50 mlnutes

-

need parent aoproval, rf parent

rs

l7 - R: a0
/:s
-

lv¡j used:

children,s contror

(

posr¡ron

3esinning

,,o concerns

,,

_

ream controt

roritro,x

f,

rranlporr posrrron

l0'.4b Êndins.mer..-'
tô:4?
",,¿)
l+ - teti?

r:oncerns, describe:

-

Signature:

Iime:

 l¿'Cnbe other

propertY d¡magel
rnlufret to olher rtudents' st¡rf and/qr

out
Descnbe what took place ¡fter time
5tudent

res¡ored the envtronmen

ituden¡

relurned to work

/
Y
.

,,att
S

quret actlvltv ln ¡ prlvate work space
student t"ns'ttont¿ to

ñ

,

about the
student and statf engaged rn a prrvate converlatron

.: "^,:-la¡l(

Student'eturned to tvor\ wrth the

X

was complete:

behav¡or

t

student retufned to gen' ed' setttng

gfoup

ln¡erv€ntlon strategret
met ¡nfornatlv ¡r r:ear¡ tc revlew current

-

taif

rvrll meet formallY a5 a team

tc revlew ÊBA/BIP (fvleetlng date/time

r)ther:

ÀccordingtothecurrentFBA,whatisthehvpothesizedfunctionofth¡sbehavior?
theculfentt¡Adoesnqt¡ddres¡rhrspantcularbehavior(meetingmusttakeplace,seea,oovetodocumentl

-his

peer ðttentlon
Ihis behavror i5 malntained by access to

to aclult attentlon
Lehavlor i¡ m¡lnt¡rned bY acces¡

fl.ìlsbehavlor sm¡ln¡atnedbvescapefromsocra lnter¡ctlon

/
ì(

ihlt

from un'preferred tasks or ¡cllvitlet
behðvlor ts m¡tntatned bv e¡crpe

to preferred ltrms/actlvrtlei
Ti'ris ben¡vror l¡ melntalned bV accrtt
f

retnforcemenl
hts behavlor ts matntatned by outomattc

the
Does this hypothesis match

L'les,

ABC of this incident?

qÞ

wrll staY the same
and lnstructlonal/interventto n strateglet
our rnterventlon wås approprlate
plan'
the team wrll review the response

¡lo, the hvpothe¡is does not

seem to mðtch thls

lncldent'

ABC data

wtll be collectedfor5davsandameettngtorevlewtheFBAwrllbe

and date above)
scnectuled {P leðse document tlme

r,Vhat is the desired replacement behavior?

How manY minutes of sPeci ally d

behavior on this student's IEP?
are rov¡ded for teaching replacement

:rllnutes and seillce

fhe tå3m rvìll need
Pa

re nt/Guard¡an Contact:

?epon completecl

behavlor
servlcc tlme to te¡ch thls replðcemcnt

ßldethod of contast:
Adñlnlltrator I¡f natule¡
incld ent.

A¡,llltrncopYolthereFol!muttbeportm¡rkedlothepaf.nt/8u¡rdl¡n(slwlthlnthrGrd¡vsofthe
Centel
Cumul¡tlv¿ Foldcr and Educarlon Srrvrcêr
:¿nd coplet ol report tol Palsnt' Student

@

 of Documentatlon:

Date

q

¡OWA CTTY
(:o\t\t(l\¡t'I
\'

tcHocrLÞt¡rucf

@

dent

Student:

Grade:

Date of lncldent:

Tlme ofJrrcldent:

Ouratlon of lncldent:

Team members lnvolved:

What was happenlng imm
flght/argument wlth

behavior (antecedent):

peer

_

student was glven a task (what klnd of

-

Student was denled preferred actlvlty or

-

Studênt was asked to

-_

Student was told to move to another locatlon

walt

student was expecteO to

)

transltlon

-

Teacher was attendlng to othert

-

Student was prompted to use speclflc replacement behavlor (whlch

one?

)

-

glven

Prlor to restraint or

qr
_

ltem

task?

n, please descrlbe the de-esca

Room clear (remove

let llmlts

attentlon (descrl

audlence)

(lf, thenl

Set a

at were attempted by staff:

ttmer JL

area

_

lgnorlng (not provldlng attenüon forescalated behavtorl

Offered cholce¡ for cool down

_

Flrst/then

promptlng use of replacement behavlor

Student

n

r to restralnt qr secluslon:.

on-o gg resslye behavior

st

nt or

beh

ïime

out:

Beglnnlng

¡ndtng

ttme: i l/r-(ì

50 mlnutes

-

need parent approval, lf parent ls

unavallable,needadmlnlstratorapproval(documenttlme/approvalll

Physical restralnt:

Yes

No

-

Chlldren's Control

-

Posltlon

Beglnnlng

Team Control

tlme;_
-

Posltlon

_

Transport Posltlon

Endtng ümel

@.tu,,ron,lfphyslcalrestralntwa3used:-NoConcernsconcerns,descrlbe:

Slgnðture:

Tlme:

_

 Descrlbe

other lnlurles to other studêntt' ttaff and/or property da

Descrlbe what took place after tlme out was complete:
Student restored the

-Ä

,rr¿"r,t

ênvlronment

r€turned to work

task

Studentreturned to workwlth the

-X

-É

c

student transltloned to qulet actlvlty ln a prlvate work space
Student and staff engaged ln a prlvate conversatlon about the bchavlor

grouP

returned to gen' ed. settlng

-

lnt€rventlon strat€g €s
UrO met tnioringtly ast t€am to revlew current
-Student

jL

Staff wlllmeetformalty

Accordlng to the current

a3 a

FBA,

team to revlew FBA/aIP (Meetlng

what

is

the hypotheslzed functlon of thls behavlor?

the current FEA does not addre¡¡ thls partlcular behavlor (meetlng mutt take place, see above to documentl

_

rn,,

-L

behavlor ls malntalncd by acces3 to adult attentlon

Å

Thls behavlor ls malntalned by access to peer attentlon

Thls behavlor ls malntalned by escape from soclal lnterastlon
Thls behavlor ls malntalned by escape from un'preferred tasks or actlvltlet

-

Thls behavlor ls malntalned by acccss to preferred ltêms/actlvltles

-

Thls be.havlor ls malntalnad by automatlc relnforcement

-Does this hypothesls

match the ABC of thls lncident?

Yes, our lnterventlon wð5 approprlate'and lnstructlonal/lnterve ntlon

¡tqtegles wlll stay the same

ñ

Yes, however our lnterventlon may have relnforced the negatlve behavlor. The team wlll revlewthe response plan.

*

No, the hypothesls does not s€sm to match thls lncldent. ABC dete wlll be collected for 5 days and e mectlng to revlew the
scheduled (please document tlme

What

is

FBA

wlll bc

the desired rep
for teaching replacement

How many minutes of

on th¡s student's IEP?

Mlnutei and servlce provlder
behavlor

The team wlll need to meet to dlscuss addlng mlnutes of
of contact:

Parent/Guardian

Admlnlstrator slSnature:

Report completed
A

wrlttrn copy of thr repoft

postmarkod to the prrenVguardlan(sl wlthln

Send coplet of report to: Parent, Student CUmul¡tlve Fglder and Educåtlon ServlC63 C0nter

@

 q[
: ite

o1

z-tí

rlocumentat¡on

.ËFì ¡()\v'\ (:¡'lY

o

:H

Y llrNtt tùltBr..r

lncident Report Oocument and Secluslon Ttme-Out Log

)
i tudent:
I ¡¡e

ci

,j r¡
cle:

3uilding

'':e

trtctoent:

ci

rncrdenl; lliùf

p+ù

l-r¡rron

of lncrdenr:

tl.ol-- lt: t7
l(),r.nr n

l+¡m memoers rnvorved:
.'ihðt ',vas naooentng ¡mnediatelv grior to rne student,s Oroolem benavior (sntecedent)l
Erti lrgun ¡nt

r.vrrn

ceet

_

:t_oent wð5 qrven ¡ t¡sk (wnåt krnd of

¡¡¡kl

l

i?m
:':uüenÍ
t/ quoent'ílt Jsl(èo to wart
-::uúèrìt*'¡¡¡¿n'edclererredðctlvllvor
:

i,..lent

-f
_':r.jent
"

i.ritS :Cl¡1 fO l..lOVe (O

rva¡ -it'Jdentwðsexoecteo!olr¡ns¡ron
ororrotec! to usr rpectilc reot¡cement len¡vrot twn¡cn onel

- IOC¡tlOn
ãntllner

rr¡t gti/en cne-on.on€ ttlentton t:ercflbe:

:Lål:

r''1r lo

restr3lnt or seclus¡on, clease descrtbe the de'escalatton str3tegles that,.vere attempted
bv starf:.
icm ':'*¡f
".j!:,¡rlt!

l/.'.a-=r,Fl
i

l/-rrrnar.J/¡jJrrendrngrocrners

t,,e¡nove

tLütenc!l _

il, Ìienl
Jiè ,lr

let I trnrer

J¿

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j l';denr oqgresstvz ben0,¿ror during restr3tnt or Seclusron:

-'r¡e out:
.

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 e

Qlults

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'r tl. ¡ tl.   ilrt trr:f

lncldent Report Document and'secluslon Tlqe.Out Log

Û

stuuent:

Buildlng:

1l.rt ts

JotÊ of lnc¡dent:

feam

Grade:

lt t l{

Iime of lncldent:

c.+--

0uratlon of lncldent:

l¿l

members involved:

trVhat was happening immediately prlor to the studen{s problem
behavior (antecedent):
rlght/¡rgumsnt with

peer

ltudent we¡ lrven

itudent rv¡¡ denled pref¡rred actlvlty- or

J

,,uo.nt

lv¿s

ta¡k lwhat krnd of task?

Student was expected to

transltlan

-

5tudent was a¡ked to wa¡t

K

item

a

reacher was attendlng to other¡

-

Sludent was prompted to use speclflc replacement behavlor
lwhlch one?

-

told to move to anothqr locatlon

5tudrnt we! glven one.on.oñ! attentlon

l)thê

Príor'to restralnt or secluslon, please descríbe the de-escalatlon strategles that were attempted
by staff:
Roomclear(removeaudlencef
5èt llmlts (lf,

Ð _

thenl

sstetlmer /-Dlrecttocool downrr.,

X-

lgnorln¡ (not provldlng attentlon for e¡calated
behavior)

offeredcholce¡forcooldown

_

¡rst/then

prompbnl ute of raplacement behavlor

Student non-dqgrcsslve behavlor prior to restralnt or secluslon:
t

5tude

oqgresslve ehavlor orlq[ to restralnt or seclusion:

Student aggresslve behavlor durlns restraint or seclusion:

Tlme out:

ur:: \ l.E*

Snding

ilme: I

tl3Þ.- ' lf duntlon exceed¡ 50 mlnutes - need parent approval, ¡f parent l¡

unavarlable, need admlnistraror approval ldocumenr tlme/ðppfoval)!

Physical

restraint:

Iî!-

'/e¡

control

-children's
:,/¡luetlon, rfphysrcrl rertratntwas use¿:

X

¡lo Concern¡

posltlon

conrrol

-Team
lì a.-

Seglnnln¡ ttme¡ I I I

_Concern¡,

describe:

_

9iqnature:

posltlon

Endtñg rtma:

\

  ( :2,p

,rrnroon posltlon

r.s

 UéJül tbÈ

other rtrluttct tu olher ttuúÈnt¡' !¡ùdlnd/of propdrn/

u.¡nt¡rBé:

o

Describe lvhat took place after tlme out was cornplete:
sruúËnt rË5tored tþe

environmenr ->C

to¡k

y'.

-

lturJert¡ t'êturned to work

-

jtr¡rlent rËrurned to rvrlrk w¡th thÈ drùup

-.-

Jtoif rnet rnformally

StUdEnt

,

rr¡nsltloned lú gu.t¡tt a':tlvlty in a private work lpor;e

r,rdant ¡nd staff eng¡geo

tn a pnvðte

convcfs¡non Jbout the beh¡vror

stuüÊnt returned to gen, ed. settrng

-

ås a teem to revlcw cuffenß lnterventlon

5taff will rneet form.rlly ¡s ¡ te¿m ro revlew

rtr¡reglès

FBA/8 P (tvteoilng

dårê/tlme:_l

othå

Accordlng to the current FBA, what ls the hypothesl¿ecl function of thls behavior?
ths üurrent fBA doet not ¡ddre¡s thls partlcular behavlor (meetln6 mr¡¡t t¡he place, see above to doüunìentl

thl¡

á

behavlor

fhls behavlor

rhli

-

attentlon

¡3

m¡intained by access to Jdult

ls

malntalned by escapu from soclal hteractlon

Thl¡ behavlor lt rn¡lnt¡lneú by occess ro pecr ¡¡ttenlton

behavlor k malntarned by escape from un-preferred t¡¡k¡ or actlvrtles

f

lrls bÉhevlor ls rnainralned by accers ro preferred itemt,/actlvltles

f

hl¡ l¡ehavlo¡ lr malntalned

bV

¡utomntlc.relnforcement

o

Does thls hypothesls match the ABC of thls lncldent?

,)s

.

YÈ5, our

lntervrntlon wat approprlate ¡nd lnstructlonal/lntervéntlon stratetier wrll stay the sarne

Ye¡, however our l¡ttervenllon may have relnforced the negatlve behavlor. Th€ t€em will review the response plarr.

l¡o, the hypotherls does nor teem to match thls lncldent, ¡sC ¿ata wlll be collected for 5 clayr ðnd a meÊttng to revlew the
!üneduled (please rJocument tlme ðnd date abovef
l(

(l

are

I

will be

lt

What is the deslred replaçement behavlor?
How many mlnutes of specially deslgned

FBA

ll

teachl ng replacement behavior on this student's lEp?

,vllnuter and servlce prov
The team

u¿rll

need to meer

Parent/Guardian Contact: o¡
Rcport complctcd

to

lscuss addlng mlnutes of servise ¡lmit t6 te¡ch thls replocement beh¿vlor

llme

&nøn
r--ï--

f'¿lethod of contact:

Ar.lml

n

lstrator

sl

gnatu re:

'¡ lvritlen copy or the l€por¡ nlusl be posÌmarked to thc parenr/gurrdlan(rf wlthrn th¡ee dayr of rhe in(¡¡JÊnt,
¡Elld coplds of report ¡ol P¡rent, Studant Curnulatlve FolrJer and Erluc¡¡ion Sen/ices CÉntet

@

 Jure vr vvrsr lqr tr¡uvr r. __¡iEtDJlr¿_

l()W¿\
s ilr¡{

a

dent Report

aþ\É

(IIIY
tilltrßì'

us¡on Tlme-Out Log

5tudent

Build

Grade:

l¡te

ïime of lncrdent:

Cur¿tron of lncrdent:

oi tnc¡dent;

leam members

tD uxr.,.t.

involve

'.Vhat was happening immediately prior to the student's problem behavio

_:,ght/arEument
!tudent

--L

lvrth

peer

_

wðs dënted preíerred acltvtty

Stu¿"nt rvar ¡iked lo

Student wes gtv€n a task (what ktnd of

or

ttem

tülk?

5tudent wa¡ cxpecred to

I

transtuon

_S.

Teactter was ¡çendlng to other¡

-

watt

5tudent was prompted to use rpecrflc replacemenr behavror lwhlch one?

Xr,u¿"ntwa¡totdromovetoanorherro..,,ff
5turJent rva¡ g,uen one-on-one attention

ô

\\

\tN/¿-- \rJ

^J

!t"" '

--

trJescribc;--

Other
-

Prior to restraint or secluslon, please describe the de-escalation strategies that were attempted by staff;

r

íìoom çlear lremove audlenc€l

:et l¡miB

l¡f'

_

set e

th€nl

trmer

are¡

Oirect to cool down

'gnortng (not provrding attentlon for escalated behavrorl

-Student non-aggressiye behavior

prior to restraint or seclusion:

ior prior to restralnt of secluslo

Student oggressive behavior durlnq restralnt or secluslon:

out:

3egtnntng ttmê

,t\'.?Ð

_

Éndlng tlme:

n\

t\

ï

T

Tlme

First/then

-

prôrnptrng use of replrcement behavlor

udent oggressive

offered cholcer for cool down

lf duratlon erceeds 50 mlnutes

-

need parent aoproval, rf parent rr

,¡nav¿llable, neeô admrnlstrator approval ldocument ttme/approv¡ll

Physical restraintl

l?s _

ilo

Chlldren's Control

po¡lflon

_

3e¡tnntns,,r.,

d'

luatton, rf phy:rcal restratnt wa¡ used:

(

n,o

Conce¡ns

t

feam Control positlon

\ì 2t

Ëndrng time:

}(

fransport Po5rtton

\iÐ

concerns, descrlbe:

-

5i*nature:

Íime:

 Þ
-.¿5çnbe other

rnlune¡ to othef ¡tudents,

llarl Ûnd/or pro0erw 0¡tm;¡le:

wðs complete:
Descnbe what took place after tlme out

5tudent iertoreo

V

;tudent

rhe

the oehavtor
¡nd ¡t¡tl engaBed ln ¡ prlvatr conversatlon about

tarl(

-'K
to !vor\ wrth the group

råturned to worl(

Student'etulned

ð pavate work space
Stu,Jent transrrroned to quiet ectrvrty rn

envronment

"uoont

o

Studênt returncd to gen' ed' setttng

formðllv a¡ ¡ t€¡m tc revrew FBA/BIP llvlc€tlnE

dateltlme:-)

3!aff nrll mee¡
-it¡fffrrtlnfofilallvr!¡:èemt3fevlêwcuflentlnterventlonStrategles
r)the r:

functlon of thls behavior?
to the current FBA, what is the hypothesized

lccordlng

:'hl¡
f

\

.

--

behavlor

l¡ rn¡lnl¡rned

hls behavto¡ rr matntatned

bV ¡ccess
bV

to adult altentlon

peer ðttentlon
Thl¡ behðvlor l¡ melntalncd by access to

e¡c¡pe lrom soct¡l interactlon

flìit

¡a¡ks or ¡c¡tvittet
behavlor t¡ m¡tnlatned by e:clpc from un'preferred

Thlt

benðvlor

f

lt mÐlntÐlned by access to preferrcd itcm!/actlvltlc!

hrs beh¡vror t¡ matntatned by automrtrc retnforcement

incident?
Does thls hypothesis match the ABC of thls

V

wlll staY the same
yEr, our tnteruentton w¡s ¡pProprlete and ln¡tructlona/lnterventlon str¡tegl€!
Yes,howeverouflntefventlonmayhaverelnforcedthenegatlvebehavlor,Thete¡rnw¡llreviewtheresponseplan.

the hypothests doei not seem to match
rqneduled (pleare oocument tlmr and date abovel

l¡o,

t

thlsincldent.ABcdatawrllbecollectedfor5daysandameettngtofevlewrhetBAwlllbe

t(

(r

t,Vhat ls the desired replacement behavior?
behavior on thls student's
lnstructlon are provided for teach¡ng replacement

How many mlnutes of speci
:,linute¡

IEP?

anct seNlce Provtder

ttms to te¡ch thls replacement behavlor
Thr tetm rvlll necd to meet to dlscuss addlng mlnutes o f servlce

Parent/Guardian Contactl

Date;

n-.,!t

?¿ PtAtethod

or contact:

Admlntstfator slgnature:

Ðeport completed
Â

{ntlen

copv ol the repolt must be po¡¡m¡rh¡d lo

lhr pir?nUguardl¡n(rI

wrthin lhr€e d¡vt of the lncrd¡nl'

l¿ndcopte¡ofrEpof¡to¡Pafent,sludcntcumul¡tlveFold¿r¡ndEduc¿tton9ervlcrtcentel

t

 -ì,rte ol Oocume ntùïon:

l()\\'r\ (il'lY
{ llrtr¡t lrt\ltaI'r

lncident Report Document and Seclusion Time-Out Log

@

5tudent:

l¡te
fc¡

ã

9uildin

oi rncrdent;

m

r1r

"t-7- li.'

G

iìme of I ncrdent:

'lut¡t¡on of lnctdent:

,6x (ì^i r

1

€ rft berS rnvolVed:

'.Vhat lvas happening immediately prior to the student's problem
behavior

-

:'ght/argumen¡ wrth

peer

itudent

preferred ¡cttvtty or

wð5 denled

Student rvai ¡sked !o

_

(antecedent): ,_
))\'w'
. ,/ irrd"n¡rv¡¡s grven a task (what krnd of t¡sk? .jf ;,:. jlJi.::

itudent

wert _

r¡em

student rvas exgecred to

çansrtron .---_

ïèacherw¿s ðttending to others

itudent rvas -prompted to use ipecttlc replacement þehavror (whtch
one?

was lold to move to another

loc¡tion

:tir,Jent '.va¡ grven one.on-one att€ntton tdescribe

-

Other:

Prior to restraint or seclusion, please describe the de-escalation strategies
that were attempted by staff:
iìoom clear lremove
set hmits lìf.

&1

_

audlence 

lhenl

¿

set ¿

tlme¡

olrect to cool down

¿re¡

-'gno^ng (not.provrding ¡trentìon for e¡carated b:havror 

offered chorces for cool down

\, ,' Fi^t/rhen

promptrng use of replacement behavror

student non'oggressive behavior prior to restraint or seclusion:

s uden

sg'yê

!o restraínt or seclusio n;
1

Student oggressive be havior durlnf restraínt or seclusion:

'lã

\-ll
Ttme

out: 3esrnnrng ,,r.'

)

2

T

i al Snoing ti.r,

rnavarlable, neeo ¡dmrnt¡tratot approvðl (document
ttme/aporoVal!:

Physical restraint:

(2s

r,to

rf ohysrcal restrarnt rver

used:

_

¡,lo

lf duratlon exceed¡ S0 minutet

childrrn'¡ control

:va'u¡tron,

'

concerns

poítion

ream cqntror

-

Seginning trme

_

-

V'4q

need parcnt aoproval, rf parent

posrtion

ândingrrme,

V

,/

,rrnrrort porrron

IZM

ccnqerns, deScr¡Òe

5;lnaturei

rs

i;r'ne:

_

 ,:i5cnþE o !hef

ttãff 0nd/or prooeftv 0¡m¡ge:

inluf lÈ3 to cthcr 51udenI5,

Descrrbe what took

place after time out was completei

3tu<Jentreitofeolheenvlfonment-Studenttransrlionedtoouietactlv tYlnapflvoteworkspace

æ,.,/ jtu

dent retuÍnrd to work

,rï

.

5t¡

studlnt and ¡tail engaged

!a'l(

O"nl 'eturned to '.vork wrrh the

rfilt rrllcfrrõllv ¡5 ¡ :eam t3

ff

rn

¡ prlvate conv€rsetlon äbout the oehavtor

Srudenr returnrd to gen' ed' rettlñg

group

0

revrew current lntefventlcn Strateglel

-

Stailtv¡ilmeetiormallya!ateam!9revlåwÉ¡A/alPlfvlestlngdate/time:}
i)ther:

AccordrngtolhecurrentFE'A,rvhatistheh.¡pothg3¡¡g{frlnclionofthisbehavior?
:hecufrrnlFsAdoelnotaddre¡¡thrsDarrcularbehaviorlmectingmustt¡keplace'leeaoovetodosument)

\/
#f

:his
hlt

beh¡vior

artentlon
Thl: behavror ir m¡lntained by access lo oeer

m¡tnÌ¡rned by access to edult¡llentlon

behðvlorrt m8lntðlncd
behavlor

aLîlì13

ii

bV

-

esc¡pe irom ¡octal lnteracllon

ta¡k¡ or actlvitler
l¡ m¡rntð¡ned bv e5c¡pe trom un-preferred

preferred itemr/actlvrtlrs
This ben¡vlor l¡ maln¡alned by accer! to

Does this hypothesis match the

J-ye5,

ABC of this incident?

our rnterventron was ¡lppropft¡te

wrll ttaY the same
¡nd inttructlonal/intervcntton strategler

response Plan
bchavior. The te¡rn wtll revtew the
ye¡. however our rnte'entron may havc rernforced the negatrve

0

be
meettng to revtew the FBA wrll

 lo,lhehvpqthes¡¡doernotie€mtomatchth¡slncldcnt.ABcd¡tðwrllbecollectedfor5d¡vsanda
date abovel
scnedu ed (please documcnt trme and
I

tl

\tJhat is the desired replacement behavior?

on this student'5 IEP?
provided for teachinE replacement behavior
are
n
lnstructlo
desiEned
How manY nrinutes of specially
:,linUte! and tervlce Provrdef
of ¡erulcs tlme
fhd te¡m lvrll need to meet to discU¡¡ addtng mrnuter

Parent/G uardlancontact:
¡eport completecl

o"rn

cþ2'

ri.ner-[Jl'

tO

trrch thit

replacement behãvror

l¿lethod of contact:

¡dmlntltrator signature:

bv

.rrrtten copv ol lhe report

d¡v! of thr lntrdenl'
to the parent/8uårdlan(!l wllhln lhr€r

!¿ndcopte¡oll?poftto P¡lgnt.sludentcumul¡tivGFold¡r¡ndEduc¡rlonsen qercenter

@

 J¡te of DocumentaUon:.

¡()1,v",1(X1Y
r lftrrr lrt¡t rt1.'¡

dcnt Report

r,- ,-a¡tg

n'Tlms€ut

ol tnsldent

Iea m m efnbei¡ involved¡.
..
.:
..:

. l.

.,,;1..:

'rVhat lvas. happening lmmedl
i,ght/ar¡um€il
!tudeni w¡i

rvrth pccr

dänred

errts problerrï behavlor (an tec.edçntl¡

..

frvcn ¡ ta¡k lwtia¡ ktnd

o,l.

pr¡lerr¡d tclrvrty or rtrrn
war aRtndln¡ to

'

war prompttd to ulo¡peqilc
ieplôcrrnent behavror
lwhlch onc?
I Student

_
Prf

{

w.t told to

move to ônothel

localloil

ltudent w¡r llven one.onon?¡n:ntlôn

or to restralnt or seclu¡lon, plÞdsc descnbe
¡he deiescalatlon :trategles
that werB ettempteð.by stafft

(Ðlr

noom ql€ar ltêmove ¡udlencel
sEt ltmlß (lt,

{r,o'orn,

-J(ser¡trmlt

rhln,

Ko,,,r, t0 cool down ¡ree Y

onrr"dchdkdr for coot down

rtnoilng {not pÍovrdln¡a*enton
fore¡c¡rbt¡d b€h¡vrorf

u¡r of rcplacenlnt b!havtoi

_

Frrtr/then

Student ñon'aggrcssive behavíor prror
to restrarnior seclusion:

en

,$

nt

5t

rt

Tíme out:

3e¡rnnrnE

:norngnms

l,',5f â

rnavarlable, need ¡drnrnrstrator
approv¡l I documsnr trme I aporcvallz

PhysicalrestraÍnt:

_i.to {r.,

Chlldrcn'¡ Control polttion

-

¡ ./
:vatu¿rron, ¡í phy¡rcal rertrrtnt rvas
ured: Z\ lro Ccncern,

@

' It duraïon exceed¡

-

need parent åoprov¡1, ,f ptrent

ream Control poltron

rr^"@
I I {ã
cl€rcribe:

3e¡rnnrn¡

_,ioncerns,

50 mlnuter

9'1na!ure:

Endln¡ rrmct

Yr,rnroort

ri

poi¡iion

 proÉlrw o¡mele:

ond/or
(her rnlullEt t0 cther ÍludËntr' tt¡il
:¿¡gn oe o
out rvas cofiplete:
tbe what took place ¡fter time

i'oescr

Sludcnß rtttoltí

itudent

the

lrwlronmrnt

¡c

rvoll rvrth tht group

!!
¡'ff rret rniorrr¡llv ¡3 ¡ ßsanr
larl

ð
rvttl meSt lrrmallv a3

¡cllvlw
d€nÌ g¡ nr¡tionãìd,tti c¡uttt

lra pflv¡t' ivoll

goact

¡bout tht othavror
tn I prlv¡tt convrlratlon
itudent ¡n¿ ¡tatt in¡¡¡3d

ttrufned to woll tStl(

úc¡ent'¡turncd

S

Stu

-

c

€d: leKlng
Studlnt fr.turßó to ÚEn'

rtfatÊgttl
revl!\ï gurgn! ¡ntËr'¿entton
i-t

ttem tc rrvrrw FBA/alP lÍvltr$nl

I

datlrilml:

r)thÊr:

d funcrion of thi! behavior?
FBA' what ic the hvpothelize
current
the
to
Åcco rding
to documÉntl
(metiln¡ mu¡t t¡k' placl' !¡c abov'
' ;
oertlcular bthÑlor
lhli
nct'¡ddrtt¡
:ne currlnt ¡¡¡'ole¡

¡ccat¡ to E€¡r ¡ttentlon
,n,, bchtvlor i¡ marntained bv

)l

-hi¡Eeh¡vlori'malnt¡¡n¡dbv¡ccer¡to¡Clult¡Ksntlon
t" :

'
' -â
" --.
--

inter¡stlon
w e¡crFc from ¡oct¡l

thl¡

b¡Favror r¡ matnta¡ncd

ilrtl

oehavror

yhrt

.tlrfithctvrtret
by rcctt, to ofer¡tred
blnrvro, r! marnlarnsd

tl matnt¡lnad

bV

etc!Í'

actlvltlc!
from un'prelrrr¡d ta¡kr ol

bv ¡utoma$c r¡tnforcem¡nt
rh¡3 !lh¡vror It mrlntaln€d

t

Does'thi5

X

ABC
hYpothes¡t match the

./es, our

olthis incident?

lnttrucdonaUlnteruentton'slratelte¡
tnteNþntlon'ta, .ppropiltts 'nd

w¡ll stav lh€ sam¡

Õ

wrll review tht rrrponrc Flan'
th: ncg¡¡trvr bchavior' fhe team
rctnforccd
have
mry
lntowentlon
Y et, howlvct oul
thc tEA wrll be'
d¡v¡ ¡nd t m€GtlnÉ to rsvlew
be collec¡cd for 5
w¡ll
d¡t¡
ÀtC
nol¡e¡nr to rnðtch thlr lncidrnt'
i.to, rhe hvpothe¡i¡ doe¡
abovll
docum¡nt ïm¡ ¡nd datt

scnedul ed lPlea¡r

',Vhat

How

13

behavior?
the det¡red replacement

deslgned ln¡tructlon are
manv minuteÍ of ¡PeclallY

grovider
l.linutes and :ervtc¡

ol ¡tn¿lct

to clhcuts eddln¡
fheie¡m rvill nqrd !o mtst
Pa

nre,

0¡tê:
rent/Gu ardien Contact:

r¡pg¡t

6Qn':PlÊtrd

bf:

2i9l)

b
for teaching replace mènt

nt's

IEP?

tlílt to telch thlt rlPlacemenl brhavlor
l/ethodofcontact;
¡dminlttrttor Slln'ture:
ol tha lncrdeñt'

¡

p¡rrnt/lu¡rdi¡nlrl '¡rlhin thtro d¡vt
mÜit oc pottrnrf¡ld ro l¡e
teoon
th¡
x¡rtln
c'01Êl
tolder ¡nd fduc¡tlon sen/lcrl
toi P¡rcñt' Sludtnl Cumul¡tivr
:Ênd cl,llÇl of rtFon
cot?

of

Õ

 Date of Documentatlon

t

IOIV'A CITY

COM}IL:\ITT
æil(xtl. riltrRl('r

'Ð

nt Report Document and Secluslon Tlme-Out Log
Grade:

ldlng:

Stude
Dat¡ of

Tlme of lncldent:

lO:

t6

Durat¡on oflncldent:

Team members lnvolved:

What was haipenlng lmmedlately prlor to the student's problem behavlor (antecedent):
flghVargument wtth

prer

student was rtven a task (what

-

]L

Student wEs denled preferred astlvlw or

_

Student was asked to

- ltem

w¿lt

kl

n¿

o¡ :

Student was expected to

lsn

171

O( lltirubinder

transltlon

Teacher wa¡ ¿ttendlng to others

-

-

Student was prompted to use speclflc replacement behrvlor (whlch

I

one?

I

-

student was told to move to another locatlon

-

Student was glven one-on-one

atttntlon

Prlor to restralnt or secluslon, please describe the de-escalatlon stratetles that were attempted by staff:

i{D-

)L

Room clear (remove audlence)
5et llmlts (lf,

then)

set a

tlmer

Dlrect to cool down

area

lgnorlng (not provldlng attentlon for escalat¡d beh¡vlor)

-

FlrsVthen

-

promptlng use of replacemcnt behavlor

-Student non-oggressive behavlor

Offered cholces for cool down

prlor to restralnt or secluslon:
t

a/.K

to restralnt or secluslon:

behavlor

Student aggîesslve behavlor durlns restralnt or secluslon:

Tlme

out: Begtnntngtlme

rl

0.'

.

I

É

-W20

Endlnetlme:

I

lf duratlon exceeds 50 mlnutes

- need parent

approvel, lf parent ls

unavallÐble,needadmlnlstratorapproval(documenttlme/approvall:

Physical

restralnt:

,/

Yes

-/-*"
-

Chlldren's Control

-

Posltlon

Seglnnlng

-Team
tlme

Cont¡ol Posltlon

-!!tr"n

port Posltlon

Endlng tlme:

t

l.f,valuatlon,lfphyslcalre5tralntwa5used:-NoConcerns-Concerns,desçrlbçl

v

-Tlmel

-

 Descrlbe other lnjurles to other students, staff and/or property

damage:

-

-.

-

Descrlbe what took place after tlme out was complete:

'

¡nvlronm€nt
,,rdent returned to work task

St¡dent

ü- _

Student transltloned to qulet actlvlty ln a prlvate work space

resto?ed the

Student rcturncd to work wlth the

Staff met lnbrmally

a3 a

Student and 3taff entaged ln e prlvate converuatlon about the behavlor

group

returned to gen. ed. settlng

-

team to rsvlew current lnterventlon sratetles

-Student

Accordlng to the current

_

x

the current

J>
å--

rt

f

FBA does

FBA,

what

ls

the hypotheslzed functlon of thls behavlor?

not address thls partlcular behavlor (meetlng must take place, see above to documcnt)
Thls behavlor ls malnt¡lned by access

b¡havlor ls malntalned by accesr to aduJt attentlon

to peer attentlon

Thls behavlor ls malntalned by escapc from soclal lnterectlon

-

tn,,

Ë-

be havlor ls

m¡lntalned by escape from un-preferred tasks or actlvltlcs

Thls beh¡vlor ls malntalned by access to preferred lteru/actlvltles
Thls behavlor ls malntalned by automatlc relnforcement
-Does thls hypothesls match the ABC of thls incldent?

Ðe

Yes, our lnterventlon was approprlatê and lnstructlonal/lnterventlon
'Yes,

strateglas wlll stay the same

however our lnterventlon may have relnforced thc negatlve beh¡vlor, The team wlll revlew the rcsponse plan.

No, the hypothesls does not se.m to match thls lncldent, ABC dâta wlll be collected for 5 d¡ys and a meetlng to revlew the FBA wlll be
scheduled (please document tlmê ¡nd d¡te above)

What ls the desired replacement behavlor?

n ck

ft.'r

n"

btgak¡r å'l lnu,r..r[r.rh]rrl5

How many mlnutes of speclally deslgned lnstructlon are provlded for teachlng replacement behavlor on this student's IEP?
Mlnutes and servlce provlder
The team wlll need

to meet to dlscurs addlng mlnutes of servlce tlmc to teach thls nplacement behavlor

Parent/Guardian Contact¡
Report completed by

Date:

Tlme:

of contact:
lnlsÛator slSnature:

A wrlnen copy of the report must be postm¡rked to the parent/ãucrdlan(sl wlthln threc days of

th! lncldent.

Send coples of report tot Parent, Studsnt Cumulatlve Folder ¡nd Educ¡llon Servlces Center

Ð

 -l¡te ol oocur¡enr¡troni

I

l'

i ,C

¡()\Vr\ (:¡'¡Y

Ë')

o

{ Itrtrt ttt\tt¡lt,.f

lncldent Repo

Sludent

trte

uilding;

oi lnc¡dent;

leem

;'rr

Grade:

of hçtdÊnt:

t¿r¡rronorrnç¡¡¡s¡¡.

.3h *¡^

members

,,Vhåt was haopening
imm

_

ion Tlma.Out Log

prior to the studenf

i gnt/rrgument rvnh pc:r

X.

:tu'Jent lvår

ot;t€m

dEntÊd oreferred ðGtlvrtt

5tuden! tr¡! ðrkëd td \yått

_

s

problem behavior

(antecedent):

_

l'ôfwñn ìnlide +--t't ¿\n
(rvhat krnd of t¡¡k?
I æc*ìvìh,t or¡-t8'r,å <,
J
lvas
.

l,ro.n,ru¡¡ i¡rvcr å talh

X,.o.n,

et0ected to

tran!rtrgn

le¡cner w¡r ¡ttanotng to
othet!

_

itudtnt,,va¡ orompted to u¡e ¡pecrilc
rsplec€ment behavrbr (lvhich
onel

!ttrdent lvat lold lo movr to ðnothef loc¡tton

-

itudent w¡r g¡ven on!.on.on! sttentton tde¡qrrbe;

,)then
-

Prior to restraint or seclusion, please describe
the de-escalation strategies that
were attempted by staff:
;loom clear lremovo
audirnce)
.
rect to cool down area

ö

d,.

}l,ro-.,

t hmrtr lrt, th6nl

\foro.orrng

Kuno,,n,

-{,,

Oíëred shoic!9 for cool down

(not provtdin¡ attentton for
e¡cal¡ted behavrorf

_

Fir!Vthen

ure ol ,cplacemrnt beh¡vror

Student non-aggresslve bchavlor prlor to restralnt
or seclusion:

s

fo

\

ent

seclu slon:

Student agqressive behavior dtlrinr restra¡nt
or seclusion:

ïme

out:

3egrnnrng,,,n",

11.37

ircinstrme;

llf{f

lf duratron e:(cgeds

.nav¡rraole, re3ã ¡dmrnrttrãlor acprov¡l (oocument
!tme/aporo.ral)

Physical

restraint:

_

.to

.(,.,

r-hrldren': contror

:'/¡luatton, í chl¡rcal re:tr!tnt

tveS u5€c,

K,

o

Ccn:ern¡

prr¡r!,on

SO

minute! - neêd oaren! aoorov¡ ,

i:am coñtror

- tr\ :,3b

3rginnlng t.me:

_,ìcncern5,

pos¡tro

,f

p¡rent r¡

^ {¡,¡nrport
indrngtme:(f@} lt

pc5¡tlon

;Bl

de3c¡:be:

',

e:

lZ.-

sc

 :.JcrlÞ'aoßner'r! ullÊltocthel'ludenls,rtartÚnd/orprooerwdi¡ña{e:
place efter time out was complete:
look

Sescnbç what

- ./

{'r,rr.n,,ranr¡lloned
rglurned lo

¿---studenl

worr

J"uotnt

tesl

group

wor\ wrtn tnr
!tu.'JEnt'?turred to
rhlñ"¡rlv !t ! ::åfn

it¡if r:t
S

r)

t'

r¡vråw

ct¡f f ent

¡nd st¡it enga8¡d rn

tt"t"t

-K.

ß ¡pact
to ourilt ¡cttvr¡y rn a prrvðte "vof

I

cehavror
pllvatc convef!atlon aoout tne

fêrurn¡u to ¡?n' Èd.5ê!3lrg

@

rntln'rnlron slrlteglet

il¡¡tt'
¡¡ ¡ tetnr t1 revrew F5A/3lP l\te€tlnt
rafi',v,'l mr:t icrmarly

t11:l:

According
:F

e

function of this behavior?

i¡ the hvpothesi
to the current FBA' what
c'Jrf

Int ilA

¡oole to do€umentì
(meeürE mu ¡t t¡hc pl¡ce, ¡eå
Èehavtor
santcular
rnrt
¡ddf €ss
'JcÊt not
bv ¡cce5s to pqel ¡trenllcn
ill't
þêhðvrof rt ñarnteined
¡ltentlon
(o
¡dult
ov accers

-htS Ce¡lvtot r! m¡rntlrned

It malntalned

oY

e!c!oe irom toctal 'nterlctlon

un'preierrrd tð3k! or ¡ctlvltlet
t! rn¿tntllned þ', e¡crpa from

ihi¡
rhis

ltem!/¿ctlvrtlel
bY açget! to plelelred
cen¡vtol rl lrÐlntalneó
¿ehavrof

lt ñ¡lntalned

bV

match the
Ðoes ¡his hYpothesi¡
'1i!.

Oul

¡utoma¡¡c relnlorcem¡nl
ABC of

this incident?
stråtegre! rvrll ¡tav the

5'mt

¡nd instructþnauin rensnllon
rnleN€ntlon wå¡ ¡Fploofttte
plln'
fh€ te¡m tvrll revlew the relponse
lhe ne8¡ttve behavtol,

may have rernforced
'/es, nowevel oul rntêrventron

@

bs
to revrew the FBA wrll
for 5 dav¡ rnd a meettn¡
collected
bc
wrll
d¡la
AðC
lecm to match thr¡ incldenl'
rto, the hvpothts r doal no¡
abovtl
(pleatt oocument trme and datÊ

¡q¡s6uled

replacement behavior?
',Vhat is the desired

IEP?
behavior on this student's
for teaching replacement
provided
are
designed instruction
How rnany minutes of specially

',ltnute5 and

gerylce PrOvrdef

íhe l?¡m tvrll need

ol
lo reet to dlscuis adding rntnut:r

Parent/6uardian Cont act:

oate:

;l,ne:

gen¡tce tlme to teãch

' l Þlf

thl¡ leglacement bchavtor

\lethod of contact:

ir{-CeU

ldmtnlttratcr Slsnature:
t.:COlt tcftcleteã bV:
mutt
å ¡¡rrtten cooY ol thr reÞort
:and ctDlrt ol

!r oottm¡rlld

l0 tha P¡retlt/gu¡rdl¡n(¡l'¡rrthrn

r¡rer d¡vr of the rncrdenl'

C¿nler
to¡dcr ¡nd Educ¡¡ron Selvrça¡
lrgorl to: P!rent' Sludent Cumul¡ttle

@

 ')¡tr

@

?;

of 00cumenntlon:

t(tlv.\ (:l'lY

lncident Report Document and Secluslon Tlme'Out Log
Grade:

Building:

Student:

'1 't/tç

Date af lncldent:

fir¡c ol

t2

lncldentt

Durðtlon of lncldent:

a

fea m rn ê

nibers involveä:

What was

happening immedlately prior to the student's problem behavlor (antecedent):

r.ght/argument tvlth

peer

ttudenl wðt tlven

- item

t¡sk (wh¡t klnd of task?

Student tvas expecte d to

stu d e nt wår denled preferred ¡ctlvlty or

itudentwas ¡cked to

a

leacher wa3 anêndlng to others

translllon

- lwhlch ont?
-l beh¡vlor
ltudent rvar -promptcd to u¡c ¡peclflc replðcement

watt
-

5tu dent wa¡ told to move to another locatlon

Studentwðr

glven one'on-one atten¡lon

r)ther:
-

&

5etðtimer

-student

of replacement

2A

Dlrecttocool

behavlor

.Jn-.

fü4

I

(.

.t

,t

J

enan¿rt^r,
Begrnnrngsme,
(document tlme/¡pproval):
r,¡ navailable, need ¡dmlnlstr¡tor apploval

nX.''"t

Physical restraint:

Children's Control

-¡lo

æ
átr 0

sit

n,

9

te

was

-.44 Sr

duralon.r.å.år"sórrl,ute¡-ieå¿parentapprovel,rf parent¡t

Posltion

Beglnnlng
u

dc
C oa

c

\

12i,4àrf

l2UL5

out:

+.

I

*

oggressive behavior prior to restraint or seclusion:

d'r

lva

offeredchoicelforcool down

O

Student aggressive behavior Cufins restraint or secluslon:

Time

downarea

non-oggressive behavior prior to restraint or seclusion':

I

5tudent

"

lSnoring(notprovrdingattlntlonforescal¡tedbehðvlor)-Firtt/then

-

Set limrts (tf. then)
use

'

-

please describe the de-escalatlon strategies that were attempted by staff:

Roomclearlremovcaudlence)

prompttng

I

- -. .

.

rior to restraint or seclusion,

.-

ldescribe:

rr^"t

leam Control Posltion *-X-.-., , ¡n¡port Pos¡tion

IL;ú

Endingtrme:

l^M

o
3 gnature:

îzi

.

 -:t?f;-

jí-:--

t her

L:cscnbe (,

lnlullet to olhe¡ ltudenl¡, 5tùtf Jnrl/or prooerty domage:

Describe what

took place after tilne out lvas

returned to work

complete:

ta¡k

V
Sru c¡ent returned to work liith the group t-

,*<rra"nt

.

f

Srs f

ffi

student transltloned to quiet actlvlw ln a prtvatc work space

nment

stu cJ e nt regtored the envtro

_

.

gtudent and staff engaged tn a prlvðte conversatlon about the behavior

Strdunt returned tp gen. ed'
. i

met lnformally rr a têam to levlew current ¡nterventlon stfat€g{et

.

t't

rvrll meer

formally as ð te¡tn to revrew FBA/BIP (fvleetlng

t

Accord in
r

h

Does

.
'

date/tlme:-)

+t ¿

e cuíent FgA does not ¡ddreri thts p¡ntcular behavlor (meetlng must take place, ¡ee above to document)
behavlor

his

l¡ m¡rnrarned by access to adult

attent¡on

Íhls behavlor

15

maintained by accelr to peer attentlon

behavlor ts matntatned by crcape from social intelactlon

This

.i_

I

to the current FBA, what is the hypothesized function of thls behavior?

g

rh ls
f

I

r rf -. '-I

u)t

I

o

setttng

..

'

'

S E a ff

:{"ïn.17

behavlor

t5

marntðlned bv accerl to preferred ltems/act¡vrt¡er

f h i s behavror ¡5 matnlatned bY

¡utomatlc relnforcement

hypothesis match the ABC of th¡s incident?

this

ve5,

our tnterventton was approprlate and lnstructlonauinterventlon

slrate6tes wrll stay the same

dayr and a meeting to revlew the FBA
the hypothesi! doe¡ not seem ro mðtch thls inçtdent. A8C data will be collected for 5
(pleale document tlme and date above)

No,
,icheduled

wrll be

Whät is the desired replacemgnt behavior?
rô

l'

provided for teaching replacement be havior on this student's
,How.rnariy mìnutes of,rfrecially'designed instruction are
t'

.

,l

fvllnutes and servrte Provtder

'

'

l,
'
f he team will need to meet to di¡cuss addlng mlnutes of sen¡ice tìme to teach thls replacement behav¡or

parent/Guardian contact:
ieport

completed bV:

Date:

3þM

ri,r,":

lZi*ãQ

Method or

.ldmtolstrator
A wntten cÖpy ol thè teoort must be portrnarked ¡o th¿

s

p¡r¡nVlurrdirn(rf

threc dðy¡ of tho incldent,

!end copier of report to: P¡rent, Studeñt Cumul¡tlv¿ Foldel and EduCatton Serv¡cei Center

.t'

a
¿

IEP

 J¡te ol DocumÊntatron:

Èr
:H

0

¡()Wr\

1

'l

/tf

(:nY

{ rh¡rt lltttxß.t.

lncldent Report Document and
Secl uslon Tlmc-Out log

Student:
Grade:

,lârê oi ncrdent

: nt

f

feam

of tñqdent!

n r.-i

l"¡r¡tlon of ttctdrnr:

y¡

rnembers

tely prior to the student,s problem behavior

{- r,uo.n,,,år
ilctli'lty
itudent,.vât a¡ked ro,.v¡¡Ì

or'tgm .-

srven

r Ësr rwhar..,"0

(

o,*

studËnt lvat eroectgó to

ClÞl-

tranSrtron

i¿¡cher w¡5 ðttrndrrg to other¡

itudtnt wåi orompteo to us€ tp€ctflc reotåcemant
- (wnich
oehrvror

onel

,

ltudentrvar told to movâ to another
- loc¡lton
jtud€ntwðr

-

gtvan one.on.one

¡tten$on rdltcft

,)thå

-

Prior to restraint or seclusion, please descrrbe the
de-escalallon strategles that were aftem pted
by sraff:

c l¿

loorñ

cle¡r lremove ¡udrencel

&!Êtt,mtrs

Stud

X-ieta.mer )t

lrf,rtenl

orrecrrocoordownår€a

ofercdchorcc¡ for coot down

*

,gnonng (not provtdlng
atrenilon for escalated behav¡orl

_

Firrt/then

Jrornpßtng u5c ol replacemcnt beh¡vror

en

t

non-oggresslye behavlor prior to restraint
or seclus¡on:

wþr
Student oggresslve behavior durtnr restraint
or secluslon:

out:

rime
tegrnnrng,,rn.,
[[,1L0 _ Èicintumr:
.iavailaole, neeo ådmtntiu¡tor aoorovðl
llocument

tlt

tL

'

rf luratlon axceed¡

ùmo/aporoval);

Physical

restrainti

_

rlo

r'?5

i'¡¡luat:on, i:hv¡,c¡l relr¡tnt wai us€d:

{hrrflrç¡'¡ Çontrol posrtron

<s,

o

ccncern¡

minutet - need oðrent aoprovð1, ,l parent

iram contrqr

-

3ÈE¡nntn3 t'me

_,Jcncerns,

SO

lescrlbei

rs

¡otrtron ¡ I ":nlport.tc:¡t¡on
-þ

:nOln¡trme:ffi3-

\:\V

U'F

e: ./4€

ll' zl

 : lscrtb,:r oßhËf

r¡tur¡es to

Descrtbe what

_êStudent

prooðlw oÛmâg€:
othtr ¡tudËnt¡' ¡¡¡¡f ¡nd/or

took place rfter

reltoreo rhr

stucÉnt'cturned:¡

ia¡x

t'16¡l r'r¡rth lhe

taii

'ltFtf
According

s

wut me:t

*r

uru¡rYt

u*.,*-

-

J

qurèt ¡cttvtw tn ¡ plrv¡ts worh soact
itu,Jent t¡an¡rrroned to

Stuc:nt rcturneu lo

-

iormrlly as a te¡m

tt

3

aboutthc qehevror
a pr*atQ conúsr¡atton
itudenr ¡nd ¡t¡tl enlrgtd ln

groug

llvlåw
t¡if rrrt lnf¡rrrSllv !¡ ¡ lerm tt
.

t-¿'

time out rvas complete:

lnvrronmen, K,

re$rneo ro worr

ç..rudenr

"ltü',[ul'tl

l'n'

ed' lentrg

current lntefl'ùntlon Strare¡let

-

rrvrew F3A/3tP ( tu€Güng

datertima:

¡

+

function of this behavior?
is the hYpotheslzed
to lhe current FBA' what
(me?tinf mu¡t takc procc,
can¡curar þehavror

¡ltêntlon

æîl'!r

-hrt

¡cca¡3 to ¡dult
cen¡v¡ori3 mttntlrned bv

fhls

rnler3ctlon
egc¡pe from Soctal
ben¡vror rl matnta¡ned ov

ihl¡

cch¡vror

;hlt

cenåvrof rr

rs

rrr

¡Éove ro ttocumentl

bV ¡ccelt lo oecr ånentlon
ben¡vlof lt marntalned

un'preferrcd task¡ o¡ ¡ctwrtlet
m¡¡nt¡ln€d bv eicapi from

fr¡rnt¡lned

bY

accllr to pleferred rtem¡/¡ctivtttes

relnforçement
rhts !eh¡vror t! rnalntatned bv ¡utomatrg

match the
Does this hvpothesis

*

ABC of this incident?

same
strategrer rvrll staY the
¡nd inrtruclional/lnterv€ntlon
¿ppropllatt
wat
'1e3. OUr rnlelventlon
plan'
rrYrll revtew the te¡ponse
tht neg¡tlv! beh ¡vror, The te¡m

'

may have rernforced
holvevcr our rntervenllon

be
'/ et,
to review lhe FBA wlll
for 5 dav¡ ¡nd ¡ me€tlng
collæted
rll
be
w
d¡t¡
AðC
¡eem to m¡tch lhi¡ lncrdent'
:lo, the hvpolhtlit doe! not
(pltelt ctocumenl trme and dalt ebova)

t

¡q,nedul ed

behavior?
',r/håt is the desired replacement

i{6r¡ rTlâfìl minutes

of sPeciallY desig ned instruction

a re

IEP?
behavior on th¡s student's
provided for teaching replacement

rlrrìrjtgS add reNlce Pfovldef

iht

re
ol serutce 0me to tesch thi3
r.o rneel to dlrcust rddlng mlnuter
need
w¡ll
lgtrn

?: rent/Guardian Contact:

,,..n.,

D¡te:

jJJL

'.lethod of contactl

¡dmlntstr¡tcf

f rgnatuf e:

?.:ço tt gcrFletect bt/:

å rrrttiñ

COPY

ol

lhr

tt ootl ñutt

0e

behavior

to tñr 9¡renl/Eu¡ldl¡ntrl'¡r(hln

thrg€ d¡vr of

th! lncldenl'

ce¡ Centgl
Folrler ¡nd ECuGa¡¡on Serv
Psrrñt' Studlnt Cumul¡rl'J!
¿no cop¡e¡ of reÞort to:

t

 ')¡teoloocumrnr¡¡o.r,

?;

l()\VÅ

9- I '

(it'tT

! ll¡ñtr tr¡rt tra:f

lncldent Report Document ¡nd Secluslon Tlme-Out Log
'i tuden

t:

Grade:

Burldlng:

'-1¡reaf tncldcnc

e-?' l5

r'l 't5,

iirn€ ol lncrdent:

;5ô

.

Dur¡tton of tnctdent.

$5 .t*"

-

feam'm e mber¡ involved:
What was

hap pening immediately

4("nrtrrgument
i tu d

prrr

srudent w¡¡ Ítvcn ¡ tð¡k trvhat klnd of

- l¡em

ent w¡¡ drnied preferred ¡Gtlvlty or

--Z;rua"nt
/rruù"nt
_

lv¡th

prlor to the studenfs problem behavlor (antecedent):

lvot ¡¡kEd to

wðlt

ta¡k?

I

ltudrnt rvü erpccted to tr¡n3rllon

Teachcr

tv¡r ðndnding to oth ?r!

itud€nt rvu -prompted to u¡3 !pectflc r€placement bêhavlor
- (whlch onel

-

war rotd to mov! to another loc¡t¡on

5tudËnt w¡r g¡ven one.on.onr ðttentlon

r)ther;

,,flot

to restraint or seclusion, please describe the de-escalation strateties that were attempted by staff:

fulnoomctear(rcmovcaudrencet
llmlts lrf,

-a.sct

;(Ouo^Otrnt

thent

.4"¡"¡r ",
'

4rrecctocoor downare¡ /otçe¡e¿chorce¡rorcoor

lgnorlng (not provrdlng rttentton lor esc¡l¡¡ed behavrort

/

down

lrstlrhen

u!c ol replacement bch¡v¡or

Student non-aggressive behavior prior to restraint or seclusion:

t

+
Student agqressive behavior orior to

traint or seclusion:
(J

5

$. l{r

0{'l"rr

€

Z

trr

ã.hu s\ ¿vrts

tudent oggressive behavior durinn restraint or secluslon:

out:

lL. ll0

Time
Begtnnrngume:
Endlnú trme: ' t?'.
r¡na.¿allable, need :dmrni¡trator ¡pproval ldocument trme/approvatl:
Physical

restraint:

_

ito

/

tts

Chrldren'¡ Control

luatlon

e¡tt ' rf duration exceed¡ 50 minute¡ - ne€d pårent ¡oprov¡r, p¡rent ¡¡
rf

i'lo Coñcrrnt

postlton /

Segtnnfngttme:l'2)

_

f rr.Control posr¡ion

_

)Y

tt.

Concern¡, de¡crlbc:
'i;{n ¡ ture:

Endingrima:

rr¡n¡port posrtion
1t>

 UÌJicrlb€ It r.ttclri'llurlflioothcrltudcnls,¡llltJn'l/orploorfryrllrn'lEe:cf¿rr ho¡¡.'J.
complele:
rr.r.scrrbe whûl took place ofter t¡lne out was

y

riltcred the envrfonfnetlt

jtudent

returned ro work

1;s14,ro.n¡
itu

_

st alf
the

f

pf

lvåtê wotk spact

thc behavtor
itudënt ¡nd ¡t¡tl en¡aged rn ¡ prlv¡lo .onvort¡tlon ¡bouÌ

group ,/rrud"nt
-

r€turned ro gen. ¿d. 5entn¡

stlateBlet
met iniorrnally Jr ¡ te3m to revlèw curlgnt lnteßentlon

:/,rr"r,
\,ì

¡tudent transltìoned to qulet act¡uty in ¡

J-

r¡¡k

rsturned ro ,.vurh with the

denr

I

wrlt meet

fcrnally at ¡ te¡m to rlvrqw tBA/BIP (fvu€tin!

det¡/tlmc:-l

:

ÅccordinE

rh

I

functlon of thls behavior?
to the current FBA, what is the hypothesl¿ed

3 beh¡vlor

fhi¡

lt rn¡lntllnèd

bilh¡vror r¡ m¿tnt¡tned

by occerr to
bV

¡dult

¡ttÊnrlon

elcape from sociel

Thl¡ behavror i¡ m¡int¡tncd bY ¡cce¡¡ to Þeef altentlon

inlerâctlon

I

- -L,/fnftbehav¡orlSdr;rrntalnEdþVe¡c¡pefromun'prefrrredta¡ksor¡ctlvitle!
nls

grelerred
ugndvrur tt rn¡ttttJtrlcd bY oc':e¡¡ to

f

hit

beh¡vlor ¡t mltntolned bv ¡ulom'¡tlc rernforcement

,i{f ou, this hypothesis
AU

llemt/¡¡ctlvltlet

f

mðtch the ABc of thls incident?

rtrðtetlet wlll tl¡y thc aðm€
nte,nentton wù9 ûporoptt,rt€ ðnd lnltfuctlon¡Uintervenllon

,r 41,

ou^

./e¡,

plan'
n€g¡trvc behavrof. fhe team wrll revt¿w the re:ponre
however our rnteflenaon mry have rernforced the

llo,

ABC dùl¡ wrll be collected for 5 d¡V¡ and
thr hvpolheslt doe¡ no!'¡eem Ìo m¡tch thlr lncident'

r-cneAütea (plerse'Jocumetlt tlme

å.nd

a

meettn¡ !o revrew thc FBA 'rrrrll be

dlte above)

\,1/hp tis the desired rePlacement behavior?

t Cr> .g)nq !i,o,nø!

i{ow

manY mtn utes of

for teaching replacement behavior on th¡s student's

s

:,ltnrJliS ond ler¿lce Provrder
f he t?am ,¡¿rll rreed

Pa

lo fieel to drtcusr ¡ddlng minute¡ ol ¡ervlce tlme

rent/ Guardian Contact:

D¡te:

ri¡ne:

,vfrtl9n

C0PY

oi the rroo¡l mu ¡t br

:¿nd cop¡i¡ of r¿port to¡

,Ð

thi¡ replacement beh¡vtor

f¿lethod of

cont¡ct: 'i¡lvrrr-L

.¡dmtntrtralor !rgnðtuf e:

?nÞort qompleted bY:

,Ð

..¡LL29-

tO teach

po¡tñ¡tkrd lo thc P¡renr/8u¡tdl¡n(rl''vllhin three d¡Y¡ ol thc ¡ncldent'

Cent:r
P¡lrnl. Stud€nt Cumul¡llve Foldcr ¡nd Educ¡tron 5ervlce¡

-

lE P

?

 t¡te of Docurnentôttofi:

Èr
.-2,

o

cldent Report Docum
Stude

l()\\r^ (:l'ly
r lt¡h{ tx\tltr.l.

Secluslon Tlme-Out Log

Building:

:3re oi tnçrdenr:

ïeam members

Grade:

;ìfi€ of hc tdent:

2uu," tron of lnctdenti

involved

'.vhat was happening immedia
tely prior to the student,s problem
behavior

_

i,ght/argument tvrth pee¡

.-

.tuden!,,v¿! dented oreierred ¡cllvltY
or

-

Sludent

rvðs atked to

(a ntecedentl:

5¡udent w¡s gtven a task (rvhar
klnd of t¡¡k?

rtem _

t)t'jle"vl ;
!',.:-\.j,vt ,!-','ç, t,t.Ll'*

student rvag exoected to transttton

_

ie¡cher wð! ¿ttenoing to othcrs

watt

-

ituÈlent wår promprect to. u!e ipecrtlc
replacement behavror
lwhich one?
Student w¿r told to move to another
- tocation

-

,

itudent

',var gtven one_on-one

ðttentton tdescrl

r)theil

Prior to restraint or secrusion, prease desc.be
the de-escaration strategies that
were attempted by staff:
loom

Jt, Lset

clear lremove

audlencel

_

rim¡rs ilf, rhent

jet a lrmer

D¡rect to cool down area

'gnonnE (not provrding attentlon for
ascal¡red

Offered chotce¡ for cool down

behavrorf

4Vstl¡h¿n

promptrng use of replacement
behavtor

Student
non-oggressive behavior prlor to restraint
or seclusion:

Student aggressive beh

prior to restraint or sec!
usf on:

Student aggressive behavíor duríne restraint
or seclusion

\
Tíme

out:

3egrnnrng ¡¡

'..i;iì
inðvallable, neeo ¡dmrnl¡ lr¡!tor
approval
Physical

restraint:

_

iro

'"ii

r-n'nsrme:

l?:51 ' lf duratlon exceedS 50 mtnutes _ need parenl aoptoval, rf parent

(dOCument trme/¡poroval):

4 /es _

':hildren,s Control

polrtion

_

re¿m Control

Jettnnrng,,,n.,;.
:valu¿t¡on, rf chysrcal reslratnt,.vâs

.
u5ed:

,tlo Conce¡ns

j- ii,\.

gos¡t¡on

:nd¡,.r8rimei

").(" ,rrnrport posrtron

í ..:.'!

l-

.:cncerns, descr,be:
:;

drì å

rs

tu re
,'n

e:

 ,:¿5cnbe o ther

'nlurres

prooertY o¡mãge:
to cther rtudenrs' rtad 0nd/or

place after time out
Oescrlbe whal look

was complete:

c

-:tudentrertorrdlheenvlronmenl-stu.Jenttran¡¡tionedtoaulutðctlvlwlnaFflvateworhspace

/

.r'

sruo"nt

gtuúÊnt ¡nd stafl

fetufñed to rvorK lasx

wolk wr(h the
Stu denl 'etufned to

')the

rvrll meet

prlv'le converlatlon about th? ochavtor

'ngagÊd

gen' ed' gettlng
Student ra$rneÚ to

group

- lnl'lv8nlton
:eam t¡ levr \r current
5t¡f f m¡t r¡formatlv r3 ¡
åtatf

In a

strðtegles

ËBA/3 P lt\leeltnl dete'
formally as ¡ t!am tc revrlw

r:

function of th¡s behavior?
FBA' lvhat is the hyp othesized
current
the
to
According

to documentì

plãcg' tee ¡oove
behavior tmeetlng mu¡t take
not addfe$ thls peßlcula r
doeg
FaA
current
:he
to oe€r ¡üenuon
fhi: behðvlor r¡ rnarntalned by acce$
ottentlon
adutt
ro
-hr:
tt matn!¡tned bV accels

_¿

!eþavlor

;hl5 bÊhtvlont rn¡tn¡atned

V ihls oehävror

l¡ rnðlntslned

bV esc¡pe
bV

f¡6¡¡ 5gçral lnterðction

taskr or âcilvltlet
elc¡pe flom un'preferred

item¡/acttvttte¡
bV ðçceri to preferred
ThiS benðvlor l5 malntalneo

!.htsbeh¡vrorlimalntalnedbyautomancretnlorcement

the
Does this hypothesis match

J',

ABC of this incident?

'/et, however our lntewentlon

negatlve
may have retnforced the

to
llo, thr hvPothe¡ ß doe¡ not seem

ã-'.0

5amE
Stratetle! wrll stav the

nleNentlon
ðpproprtate ¡nd in¡tructlonaul
ur,our rnterven¡lon wðs

m¡tch thi¡ incident'

@

the respon5e plan'
behavlof. fhe te¡m wlll review

ABC dðta rvrll be collected

review the
for 5 daVs and r meettng to

FBA

wrll be

date above)
(please oocume nt ttme and
2

,,r/hat is the desired replacement behavior?

IEP?
behavior on this sudent's
for teaching replacement

of sP eciallY design ed in
Horry manY minutes
:,1rnuts5 and servlce Provtder

telch thls replacement behavior
mtnu tes of seruice ttme to
to meet to d¡scu3¡ adding

Parent/6uardian Conta ct: o¡te

Time:

-.'
^.Jã

J

f

'¡ethod of contact:

\dminrf tratof

),:polt cofnpleted

bY:

¡

xiltlen copv ol th¡ feport mult

5r

gnature:

wtthln thtee davs of the tnclden¡'
to lhe p!rcnt/8u¿rdi¡n(¡l

¡nd Éduc¿¡lon Sefvrce3 centol
Sludênt Cumul¡live to¡der
:¿nd coplet of report tol Prrent'

@

 t

q

t\

-1lte

oi OocurnenlaUonl

'<

low,\ (:t'¡Y

,sþ

U ltrtrt

tllt[¡a.f

lncident Report Document and Seclusion Time-Out Log

iLudent

õurlding:

'3

ra oi rncrdenr: I I 38

:lta oÌ lnc¡oent:

"::m rnembers

- 3 l3O

rad e:

ll

:rr3!roñ cf rncidenr:

n^{ntr

l¿s

rnvolved:

,'/hat ,,v¿s naopenlng rmrnediatelY prior to the student's proolem behavior (antecedent):

_

SUrnenf wr(n oeef

¿clrvrtv gr ¡tem

_

::u!¡e[! wðf oenred oreferrrd

_

-(udenç.¡r¡f ¡llect to

_

'tuden(',v¡s (old (o lîove to-¡notnef loc¡t:on

_

"v;ilt

_

¡ ta¡k (wnðt krnd of

,.vã5

ry

i¡¡cner,^vlç ¡t?tñailnt rn

olomoteo to u¡e spec¡flc teotacemeñt cenavtof lwnrch onel

rüercnoe:

,j

,_ ,

¡"ior to

task?

:tudent w¡s eroected to trlnstUon

;luoenl

i:utent'.,,,¡i qlveñ cne-on-ore ¡tìen$on

,ìFér:

&ì

iI,.¡dênt '.våg lrvÈn

,

.

.

restrarnt or 5ectusron, please descrtbe the de-escalatron rtrategtes rhalwere attemoted by staff:.

:dorlì i

ê31 lr¿movÊ

iet a trrnet

auOtenCel

-)

j
-

:',t 'rn,tt r,l, :Ienl

:,rect to Cool down

j"or,"g tnot orovrolnç
åftentron lof
-

_,:i?rñct;ri ti¿ c¡ f:t'¿c:Íent cgn¡vtor

¡iilered chotce¡ ior ccol .jown

areå

à5calåreO

iir:t/lhen

!ehavtoll

-

J:ner:

:..ì,Jdent nan-aagresslve oeh¡vrr¡r oror t0 restratnt or Seclusron:

frr*
itudent

-'me

oggresstvg beha'¿ror durine restraint or Seclus¡on:

oul:

Sigrnn,ng',t"'

l:t{J

¡:.crnrrrr¡Êl

3tslo

- ' 'f Cur¡tlon exce:ot

50

,¡tnu¡:¡ - n¿ed c¿r?nt !oorczal, ,i oargnt rl

..à,,/àll¿ble.r?lc3dm nrÎrãtclaoofova¡(oocurner:ttlrne/aoprov¡I} 

*

0,rr, e,

Á

ô€e {anroo$,'r'uÞ \ott"l
y',*,

rhysical restrarnt:

-(r.dren',

-'ic

@ì \:'/JiU¿ttCn ,
)

;

;''¡; c:l

r?5!!'atrìt ,,/åt rr!Êc:

$"n¿

ö{-

conr¿?t p?srr,rn
3:grnnrng

?

{:.:r'l:?rnl

_

inu
_

lrn:

d¿
-?trn

' i.'i.6

ll:¡cerns, 1gscflCå
)',î"t'1

^\-

!¡r:rol ¡oslt on
3n1rrg

lrt

-_

-.1-!pcír Pc5::'on

l:a(o

.

 { S¿\Ç iNJ'rcY latç
)c Sø\Q

i^'l"Y bgVravi o15
loqAPüt¿r

råothellnlul e!toötherttudenl!,rtgrf¡nrl/orpg
what took place

'lbe

rr.Å
,,:tuoent

festgred the

envrronmen!

,

 

5f
- -.student

rnet,niorrnallv

; taf

f-r

k\'¡p

ßr¡drzlin¿

c-

,û
y-'

group

¡! ¡ t?am Îo rlr'tew

i writ fneÈl iolmallv

!t

pllvate worx space
tr¡n6rtlon€d ¡o qulet ¡ctlvrw rn it

i(uoent ¡nd staí engâged rn

.itudent returneo ¡o rvofl(',vrtn tl'e

- l:¡ ri

d¿r.

¡iter ttme out was complete:

)t'"o"n, reluf neo ro wof r( t!sr(
.

-

e teåm

ltudent returned to gen'

'

prrvare çonversåaon åbour the oehavror

èC' Êeltlng

curren( lnt!flentlon strate¡let

to revrew F3Ñ

BIP

 

Ñteetlng datei

lirneì-l

r:

ordingtothecurrentFBA'lvhatisthehvpothesizedfunctionofthtsbehavlof?
:i.zcUrrentFSA,JcetnotsctofefStnlsc¡nlgulðroenevlor(rneetlnImusttakeplðce,reÊ¡oove(odocument}
-h

'

e beñãvror

ll rí¡lntalned

bv

ihrs cenavrof ts marnta¡ner¡ bv ¿ccefs to ¡¡eer atte

aice:¡ to ¡dult ¿ttentlon

-.,rl5benðvloflfm¡ln(alnEdbvescaoelrom¡oc¡¿llnleraßtlon

:tì!i

bgnavlof

lt rîðlntalned

-'ìr5 C¿l¡vlÙl rt l]1 a'ñt¡lneo

-

bY å5çäoe
oY

trom un'prererfÊct

t¡tkt or'lc(lvl(le¡

{e

¡ccesi lo orefêlfr{l ttent'¡ctlvltles

,Þ-'

-ilr3 !enavrol ¡i m¡lntalned ov ¡utomatlc rerniorcemen¡

- rhis hvpotnesls match the ABC of this incldentl
)es
strotegeswrll ¡tav th! sôrn€
..ts, .rur ¡(eñent'on wili approprlate ¡nd ln3tfuctlonal/ln(ervenron

-

--_,.]f.lq..vevelOul¡ntê1/€ñtlonrnavnavrrelnlofcect eñ gatlveoenðvlol.íleleÀmlvtllrlvtewthere¡oon¡eotan.
j¡r¡w'il ieiJrìecledlcr5d¡'¿sl.cð-eetlngt!"r/1''rr'nçi4A'erril
,¡ú...i.drìyoulnesrrr¡ùÈiùotteerñiof¡t.n¡nr9rnûcen!, A5c

)
l"a

¡nd dstr ¡oove)
:1?O!recl tolease oocuÍenl ¡t"ne

'/h,¡[ ts the oeslred replacement benavlor?
.¡o,

on tnts srudent's rÊP)
are provrded for teaching repracement þehsvror
insruction
desrEned
snecratry
oi
, rrìanv rrrnures

.: lrrtes AnO Servlcê C(AV Qet

,/

lhrr rêoracemenr senavrof
-,--1:¡m'.lrrr reld !o rne€r ro rrsc.J55 ¡.Jdrng m,nutef oi lerulct trne to :eâcn

:¡¡ç¡r/GuardranContact: cùte: .q lS
?åcoft :tr¡!ìited

/fS

'r.:¿

?l'19-'. '

:'tatrrodof c¡n¡act:

¡dmrnrstrltor 5l3n¡ture:

b'/

.l xrrr:eñ c¡oY ol lFe feoott murl:e âcalmrlkeó to:ne oarent/l'rafotåntll
-¿rrã

'r

forjer lrd 3'J'¡c¡t'on:¿r'/lce5 Cel'tet
€?' e! of ,eport Ìo: ¡ìf !ñ1. 5¡ltent C,Jrnill¿lul

r€

 )¡te of Documentatton;
I

SJ

&

ent Report Docum
Student:

:lre

leam

I

'{ llr lrt In\t ttr.f

tandS

uslon T¡me-Out Log

3uildf ng:

oi tncrdenç

i'

I()\\rr\ (:l.lY

Grade:

;;me of tnctdenti

t¡on or rncrden

rt 43_Mn

members tnvolved:

',Vha t \,vãs happening immediately

e student's problem behavior (antecede

f'ght/argument lvrrh peer

-_

ltud ênt tv¡¡ oenred p¡eierred

_

itudent

wa¡ ð3ked to

(rvha

actrvrty or trem

walt

ted to trðnslllon

¿¡cher wa¡ ¿ttcnotng to others

_

ituden I ',vat promptect to use ¡pectflc
replacement behavlor
lwhlch oncl
-itudent wa! told to ñove to ¡no¡her loc¡tlon

-

dent',v¡5 grven efi€.oñ.0ne attentron
I delcn

r)ther

-'ituI

Prior to restrai nt or seclusion' please
descrtbe the de'escalatíon
strategies that were attempted
by stãff:
iloom clear lremóve audlencel

6-l

Set

_

Set ¿ trmer

timil¡ fif, then)

¡gnonng

0irect to cool down are¡

lnot provtdlng attentton for escalated behavrorf

_

¡Jromptrng use ol replacement

Stud e

nt non-øgg re ssiye behavior prior to restra¡nt
or seclusion:

Studen t

behavror

behavior

0ffered chotces for cool down

{

r,ru7,nun

Othe

to restraint or seclusion:

5tudent aggressive behavior dqfine
restraint or seclusionl

Time

J

oUt;

3egrnnrng lrme:

l:"fu

indtng tlrne
nðv¿rlabje, neeã ¡dmrntS(rator
ðporoval (docu ment trme/aporoval):

Physical

restraint:

%

_,.to

\,/

,",

llo concerns

-

Ìf duratlon

lhr;oren's Coñtrol

!valu¿t¡on, ,f chyt,cal reltratnt,,vas
used

'

posrtlon

3eginnrng

_,Jcncerns,

:Íceed¡ 50 m¡nutei _ need p¿rent
aoprovã1, ,f oar!nt

*

t.rñer

descnbe;

:;in¿ trrr?:

ieam Control position

.

ãnct,ng c,mer

*

r¡

r,ansport posrtron

 prooertv oitmäl€:
to cther ttudEnts' ttarf ¡nd/or
,l¿5cnbe othel 'nlullei

Descrrbe what took
:turJent rlstoled

place after t¡me out rvas complete:
¡ctlvrtY rn a pf
Student tran srtioncd to oulet

the envlronment

retuf ned to

itudenl

stuoenl ¡nd

wor[ (asx

Staif

:i

lrfcrmatly

rvrrl

¡t¡lf

åccording

vlr.'

lvtl€ work space

ðbout lhe oehavtor
engaged rn a prlv¡te conveltatlon

@

tnteruentlon :tl¡leBles
¡ :e¡m lf, reì'tew cullent

meet tormðllv

¡r

¡¡

date'time:
team lc revr:w F3A/BlP lÑleetlng

r)th€r:

-'

W+.w

,ú t¿

sentng
student rêtufnro tO gen' od'

lne grgupwor\
Siudent'eturned lq
"vrth

<tJif mit

ç

1.

funcrion of
is the hVpothesi¿ed
to the current FBA' rvhat

thi¡ behavior?

prace, see aoove ro documcntì
behavror (meeting mug! ¡¡ke
oar$cur¡r
thlt
addreSr
curr¡nt FAA doet not
!o geef ðttentlon
Thil behavrof ts matntatned bY ¡ccess
ðdult
to
åcce:t
[eþavlol i¡ m¡rn!¡rned bv

sttention

!'hrs
-:he

,ï1.ìl3beh¡vrolrlm¡tnlatnedoYesc¡peírornsoctallntef¡ction

\

/

Ílìlg

oehavlor

15

¡ålnt¡lned
rrl

This benavlol l¡ melntalned

task¡ gr actlvltlet
bv e¡c¡pe irom un'prefered
bY acce¡s to

pretelred items/act¡vtttes

the ABC of this incident?
Does this hypothesis match

)L

./es,ourlntgfv€nttonw¡¡rðppfoprlateandinstructlonaui.nterventlonstrateglêswrllstaythesame
the resPonse Plan
Yes, howevelouflnterventlonmayhaverelnforcedthenegaovebehavror.fhete¡mwtllrevtew
for 5 d¡vs a ñd
ABC d¡la lvrll be collected
seern to match thi¡ incrdent'
not
does
sr¡
hvpothe
¡lo, the
above)
(pleare docum ent tlme and datc

t

FBA wrll be
¡ meetlng lo revlew the

5ç¡sdulêd

,l/hat is the desired replacement behavior?
How manV minutes of
:,linula! and servlce

this student's
replacemenl behavior on

sPe ciallY

Provrder

dircusr addlng mrñute! of
lhe le¡m wrll need lo meet ¡o
PA rent/Guardian

IEP?

Conta ctl o¡te:

3en¿tce

behavior
lt me to teach this replãcement

,i''.' 3'{5

,'/tethod of contact:

\dmtnlslrator signatureì
rÈÊort cornpleted bv:

i

of the lncrdenl'
p¡rent/8uðldian(rl wrlhln three d¡v¡
mult bo 9o!tm¡ rted lo the
¡rftlÌen copy ol rhe leport
Cenl€r
Folder and Educ¿lron Serv¡ce¡
P¡r€nt' Student C\¡nulåtive
:¿nd coqrei of lepott to:

@

 JJ(e Of uccumentaUon:

l()\\'.\ (:nY

Ð

o

Y il. ¡rt trtlt $r.f

Report Document and Seclusion Tlme.Out

5 tuden

Building:

D ðte cf lncldantl

ilrr.e of tngdenn

Team memberi
t¡Vhat was

Grade:
rR

'.J19ùt'on

of Incrdent:

involved:

happening

;'Bht/ar¡umant wrth

ior (antecedent

pe€r

student war llvcn e t¡rk (what k nd ol

- rt€m

-

itudent

-

Student w¡t ä¡k€d to

wet dcnied praferted ðcttvtty or

t¡¡k?

.

..

trud.n, war expected to transttton

'\

watt

I

TêðchÊr

wat anrndtn¡ to othcr¡

-

Student war promptcd to ure speclflc repl¡sement behavror lwhlch on¡?

-

Studcnt wat told to movc to ¡nother locatron
Student wðr glven one.on-on! attent¡on (de¡crrbe

**

ce
or

restraint or seclusio n, p
Room cle¡r (removc

t

-¿S

set limitt lif,

I

Student

ïime
u

\/

On"ct ¡o cool down

aræ

Otfcred cholce¡ for cool down

Inot providtng ¡nenrton for e¡catared behaviorf

Firsr/rhen

-

non-oggresslve behavior prior to réstralnt or seclusion:

ctv

oggressive behavior

(

\

to restraint or seclusion:

.Èr

oggressive behavior durinq restraint o,r seclusion:

out:

Begtnnrng,,r.,

lf lJ 0

Endingtrme:

ltrnS

.tf dur¡rronexceed¡50mhurer-necdparentapprovat,rf

parenls

navarlable, need admtntstrator aoproval (document ttme/approv¡l)

Physicalrestraint:

Yno

V!¡
-

Chrldren's Control

-

gvaluatron, rf physical rertralnt wa¡ used:

qß

tlmer

)Ltgnorlns

Screc,
S

set a

prompnn¡ u¡e of replacement behavior

tudent

<l.,t +\ rnkrr

strateBies that were attempted by staff:

audtence)

then)

r¿\r) <rÇt*

l¡o concetnt

-

Po!¡tion

geglnning

_

leam Control Poittlon

time:_

_

Irenrport Por¡tlon

Ênding ttmè:

concern¡, dcsc¡rbc:

s:Bnature:

Íi¡ne:

_

 Þescrtbervhattookplaceartertlmeouttvascomplete:
Student r€trcred the

Nnvironmcnt

,î\7
I )( .student rlturned lo work tark
-.,'ficl
L''- ;¡uarnt rlturn.d to woil lvrth the group

¡pacc
Student trans¡ttoned to qu¡Êt ¡ct¡vlry ln a prlvate work

itudrnt and rt¡fl engaged

rn

¡ pnvatr

conver!åtton .bout thc behavror

o

Stud.nt returncd ro Etn. rd' sentng

it¡ffmetlnformallYåtate¡mtolevlewcufrrnt¡ntlfvGntlonrtrat€gltt
5

t¡fl

rvrll meet

lotm¡llv a! a team to ruvrcw FBA/8 P ltvte:thg

date/tlme:-¡

Other:

.\ccording to the current tBA, what

ls the hypotheslzed function of thls behavior?

must takt place,
rhe surf€nt tBA doêr not eddr€t¡ thit panlcul¡r b3h¡vtor tmætlng

rhlt

behevior lr m¡tnteined by accclt

fhll

to adult ¡nentlon

3ee

¡bovc to documentl

bsh¡vlo? ¡t m¡inta.nrd þY acce¡¡ to prer attentlon

f hl¡ beh¡vlol l¡ maint¡lncd bv e¡cape trom ¡oct¡l lntelactlon
or actlvttle3
bch¡vlor It malnt¿lnad bv c¡cepe from un'prcftrted talkc

-fhl:

ïhli

behavror

l¡ m.¡ntalncd by acce$ lo prcflrrrd ltemt/actlvltla¡

beh¿vior i¡

m¡lntatned bv autom¿tlc retnforsemcnl

Does th¡s hypothesis match lhe ABC of this incident?

-Thlt

y

--?G.ì-

thc samc
yes. our rnt?Nen¡lon war appropriatt and lnrtrustloneUlntervenüon ¡Ìratetle¡ rvlll stay

A8C d¡ta w¡ll be collected lor 5 daY¡ and
t¡o, rhr hypothesl¡ doc¡ not 3e!m lo malch thll lncldent.
rcheduled (pleese documcnt tlme and date abovrf

Õ

What is the desited replacement behavlor?
How

manY minutes of sP

Õt-ù tV\
are

desi

a meetlng

to revrcw theFBA

wilrufl

Cl'' I

lÉP
rovided for teaching replacement behavior on this student's

þl¡nutet and sery¡ce Provlder
The

ttâm wrll need tomeettodlrcusraddln¡mlnute¡olltrulcrümÊtoteach¡hl¡replacementbchavior

Parent/6uardian
ìeport

q

Co

,,'.' 3:V5

tvlethod of contact:

(

tiS,naturt:

comPle¡ed
A

wfltten copv of thc report
Send copro¡ ol report tot

lo the parcnt/gu¡rdlen(¡l wrlhln thr¡ç d¡v¡ of thc incldrnt'

P¡rlnl, Studcnt cumul¡ltvc Folder and EduG¡¡ion service¡ centcr

æ

 J¡'te o i Do.ur.ntot,onl

6

Èi
.H-

l()\\r'\ (:¡'lY
'{

}lr

hrt ttl\ t t¡tr,t,

lncident Report Docume nt and
5

tudent

slon Tlme-Out Lo

Sullding

I3te oi tncldent:

i- tL -l 5

rade:

ii,.ne of tnctdent:

luratron of lncldent:

feam members rnvolved:
',Vha t r,vas happening immediately
prior to the student,s problem
behavior (antecedent)l
:,gnt/ar'umen! tvrrlt

tz

ltudent
"vð5

_

Feer

_

denlÉd preíerred åcttvrty

or

Student rvðs gtven a tark (what
krnd of

rrem =-

t¡sk?

I

student was exoected to lrant*ron

Teacher w¿¡ ¡ttenolng
to other¡
5tudent wes orompted to use
tpecrfrc repracement beh¡vror
¡which one?

Student lvas a¡ked to ,,v¡ttt

wa¡ !old lo move to ¡nothef
loc¡tion

-

jturJent w¿r gtven
one.on.one
-,itudent

¡tteñtron tdelcribe;

r)th
- er

prior to restraint or
seclusion, please describe
the de-escalation strategies
that were attempted by staff:
:ìoom
cleðr

g};,.,

I

setatrmer

;;;ïeåudrencel
promp,,^r rr.

-

Ðirect to cool down

tt:::11t"' provrding

*;
",'l*,.cemenr

a

area

Offered choices for cool down

tten gon lo r esca lated behavror,

+^/.'ri

r rt¡ 1¡"¡

student non'aggressive behavior prior
to re5traint or secrusion:

Student

behavior

lo restraint or seclusionl

.i¡li,\-,1I
,

1,,-.

l

:)þè,:DL(

(LúLtvu

Student ogg ressivg behavior
dur,inf restraint or seclus ion

Ïime

out:

3egtnnrng

ïmei

rñAvðrlable, neet ¡dmtntstr¡tor pproval
a
(document trme/aporoval);

Physical

restraínt: _,:12

,-// t4

Cirirdren's üonlrol

ivalu¡llon, í chv¡rcal rerlratnt,,vð!

u5ed

_

'

rlo Ccncern¡

lf duratlon exceeds 50 minute!

postlion

3egrnnrng

--'ìcncerns,

-trmel

- need oa¡ent aoproval,

feam Conlrol posrt¡on

-

l¡

fransoor! po¡l¡;on

ãnd.ng trme:

de¡crroel

i'jcatu,'?:

¡f pa¡ent

¡:e

 L
,:¿scrlbe other 'rllurlet

ðnd/or pro0'ftv d¡mãge:
to cthef rtudÈnts' t!ðñ

c

place 3fter time out was complete:
Descnbe what took

itudent
I

/

studrnt ¡nd

retufneo to wofr talK

;tudent

--3-

--

reltored the envllonment

Studen! transrtioned to

: !ait

r)thel:

¡ccording

rvrrl

'.

,l

work {tËce

-tiL,rtrrL

,#t

uvut

.'

to gen' ed' setttng

Stralegles
fevlew currlnt lnlcn/Sntlon

of this behavior?
is the hvpothesi¿ed function
to the current FBA' rvhat
¡¡
pantcular b€havior tmeeting mu
doet not eddtes5 thrs

¡¡ls

place, ¡ce ¡oove to documentl

bv ðccess to geef ðttentlon
fhis behtvrol r¡ marntained

-hl3 beFavlor-'-ll ñaln¡¡lned bv acce¡s to actult nltention

/

(Ll/l)d'

dare/
revr:w t3A/alP lrueetlnf
me€t iolmallv a5 a team tc

:he currlnt t¡A

//

!l

¡r ¡ :a¡m

tna

ctc

about thc oehavlor
engagcd tn a pflvate çonvelsatlon

Student rèrurneo

wrlh the group
SiucJent'atulned lo wor\

it¡ ff n':t lniormatlv

¡t¡f

it,
qulet

WL)

&L

I

Ihlr

behävlol

ilìlr

o€havlor

lt ilslntalned
15

oY e5cåpe

irom roclal rnlellctiqn
-

gr ¡ctlv¡tlet
un'preferred ta¡k¡
lrlðtnt¡ned bv esc¡pe lrom

ro pteferred rtems/acttvtttel
benåvlor l! m¿lntalned bv access

-ÍhÌ9

rernforcement
rhts beh¡vlol t¡ metnt¡tned bv ¡utomattc

the ABC of this incident?
Does this hypothesis match
our rnterventron w¿!5

!-'le¡'

nterventlon
appfoprlãte ¡nd in¡tructlonal/i

same
rtrðtegles wrll ltay lhe

pl¡n
fhe team wrll review the response
rernforced the negatlve behavior'
havc
m¡V
'/e¡, however our lnterventlon
the FBA wrll be
å meetlng to rëvlew
collected for 5 dav¡ and
bc
rvrll
d¡ta
ABC
to match thi¡ lncldent'
flo, the hvpothe:t¡ doe¡ not teem
above)
date
(pleðle oocument ume and

O

scnebule d

'l/hat

behavior?
is the desired replacement

IEP'
behavior on this student's
ided for teaching rePlacement

peciallV
How manv minutes of s

te ¡ch this lePlacernent behavior
mlnutes ol seruice tlm€ lo
addlng
d
iscuss
to
meet
to

ct:

Tlme:

o¡te:

1-

í)rr/å

^/)

tulethod of contact:

Àdminlstlatol 5ignalure
1¿poft completed

¡

¡/t'tten

c0PY

ol the rePort mu¡t be

:¿nd coplet of

Po ttm¡rted

tlpott toi P¡rent'

rncldent'
wrthrn threa d¡v¡ ol ttre
lo the parenl/Euarcti¡n(5)

and Educ¡tlon
Studenr Cumulative Folder

gelvrces Center

m

 -ì¡¡e of oocumentiruon:

q -l{t f
S

lo\vr\ (:l'lY
t llr ltrl lil\ I trI !r

Ð
û

lncident Report Document and Seclu¡lon
Time.Out Log

student:

ldíng

.l.¡te oi tñctdenti

6rade:

ï'nrc of lñC'denti

:ur¡ttoñ of lnqrdrnt:

I

M

feãm membert
..Vhðt was haopenrng
imm
'gnt/argument

'

-

i tu d

to ¡he Íudent, r problem behavior (antecedent):

rvrrh ceet

r,ro.n,,,vas ¡rvcn ¡ ra¡k (rvh¡t krnd of t¡sk?

$

ent w¡t oenlrd orefrrred acttvrw or

ìtÊm .-

_

jtudent w¡r ¡rkcd

_

itr.rdent rva¡ told to movr to another loc¡non

to rvatt

srudent was eroÊctld to tr¡nsrtron

wag ¡ttendtng to

otherr

itu'Jent w¡¡ orompled to urr rpec¡irc reprãc€menr
behavror rrvhich onel

-'ercner

-

:turJ€nt ',v¡t gtven on!-on.one ¡ttentton túercrrbe:

r)rh€ri

-

Prior to restraintor seclusion, please descrtbe the de-escalation
strategies that,rvere attempted by staff:

iloomclr¡rlremoveaudlencrl 5et¡ttmer

O

let

+(*

lrmrts f ¡f'

thenl

-*

lromÞtrn¡ ure oi reolacement

Ðirecttocooldownare¡

-)l-

gnotne lno, prou,o,ng ¿rrenrron for
e¡carared

behavtor

lC

offeredchorccsforcoor down

o.n*,"rtllr¡rrtrr¡en

Othe

Student
non-oggressiye behavlor prior to restraint
or seclusion:

"t
ent

dþ

b

aggressive

ior prioÍ

t or seclu on:

+

.$!.[&[s,.!#ln

+

seclusion

t/\L
îirne

out:

3asrnnrngtrme,

f 

:L{0.

¿"dtns$me:

ll, qU

.¡avArlaole, r3:0 ¡Cmtnt5rratOr aogrOv¡l ( dccument
trme/aoorovat¡:

Ph,Tsical

restraint:

_.to

'3¡
-

:'/¡iuð!¡oñ, í chv:.cal ¡e¡v!tnt ivðt

used

control

-'l\rlcren'¡

lc

' lf Jurðtton excsedS

pâsrrron

3rg¡nning trmet

iloCcncernr _,Jcncerns,

Jelcribe:

!

gna

-

50 minute3

-

ñe:C carent ðoprovel, ,í carent r¡

ieam conrror tos¡ton

il :tq-

:nd¡ns arñe:

Y ,,,,rn oort rc¡,tion

[l',

?ç.ì

 Descrtbe wh¡t
itudent

r

ocerw 0ümagÊ:

pf

to cthel ¡tud€nl3' ti¡rl tnd/ol
::5crtbe oßhef 'nlurrÉs

completel
took place 3fter time out was

r?ttcfrg lFr

l9act
rn e prlv¡te
ttudent tl¡n¡r0onld to c¡ulet ¡ct¡vrry
"vorl(

envlfqnment

o

V'l^-.^'-'ù"'Lituoent¡ndlt¡ilengagrdlnaprNatËconvlrlatton¡boutth!ochavtor
r studerrr returned to woll tatl(
tle
siu'Jent'?tufned !c work wltn
5t¡f f rr:t.rrl:rlrlrly

-

5¡aii
,)th?l

w¡rl

5tu'Jent rerurncó to Srln' à0'

gfouÞ

¡5 ¡ !êåm l2 levr'i!!Y ct¡rrant

n:e:l i?rmlltv

¡t å tetm lc rlvtlw

'ÈnrrE

lnt!r'entlon ¡tl¡tefles

Ë¡A/alP l[tee$n!

d¡te/tlme:

I

i

Åccording

.T
V-

;hlÉ

of
is the hvpothesi¿ed function
ro the cuffent FBA, what

írom un'preierred ta¡kr or ¡ctlv¡tlet
ceh¡vtar r¡ rn¡tnt¡tned bï êtG¡g!

the
Ooes this hypothe:i¡ match

jc

thit behavior?

ABC of

thil incident?

lvrll ¡tay the ¡ame
¡nd in¡tructionau¡ntÊrïentlgn rtrategrel
'j€9, oul lntenrln¡lon lvai ¡pprogrlate
plan'
wlll revlew the rerponsa
thÊ netatlve beh¡vlor' IhE team
rurnforced
n¡vr
m¡V
Interuentlon
'/er, howevel oul

t
¡he FBA wrll be

llo, ththvFolhetlldoernotlermtomatchthlglnc¡denl.AacdôtlrvrllbccollcctedlorSd¡v¡andameettn¡torevlew
icneouled

(PlÉ¡llt cocument tlme ¡nd d¡te above)

ent behavior?
',r/hat is th.e desired rePl¡Ée$

ù¿,Ðrvq

..lo,¡ttlnadV

Srd'(¿ttly
are
minule5 of 5Þeclal ly desig ned instruction

:r'linrJ¡3¡ and teNlçe Provlder

-le lrlm wrll n¡ed to rneet 10 discut¡
Dote:
P¡ rent/Guardi an Contact:

IEP?
behavior on this stu dent's
ided for teachin replacement

tetch thtr reolac€mrnt beh¡vtor
adding mrnute! of isn¡rce llme to

,rn"r3!L

),lethod of contact:

¡dmtntstf etcr srgnaturl:
?

¡Êort ccrçlelsd b'r:

i

3c
.vrrttln (op', oi rhr reoott nu3t

!¡ro

coprel of regorr lo:

00 ¡tmomd to

d¡v¡ ol
lnr 9¡trrìt/lu¡ldi¡n(:I wrthtn !hr!6

rhe rncldenl'

Educ¡¡ton Scr"rcet Cênllr
P¡lln!' Sludent Cumul¡tt'¿l Fold!r ¡ñd

t

 J¡te ol 0ocument¡ïon:

c

È?

¡()w.,\ (:t'tY
{ ll.htl

InìtNl¡.f

Document and seclullon Tlmc€ut
5

S

lol

ludent
Grade

I rtt oi tncrde¡¡:

feam

iin

g sf

t¡g¡¡3r¡.

Jur¡tron of lncrdent:

\^Ä

member¡ involved:

'.v hat tvas

haopen in3 immed
wrth

to th€ student'! probrem behavior
{ante€edent):

geer

í
rvðs ¡rven ¡ tark
_.tudenr
hvhet k¡nd of t¡¡k?
: t u dent w¡r centçd crelerred lctrvrty
ot rtem _
itudSnt rval !¡ocgtad to tranrrtron

-t/-,rnr/¡r¡umenr

ltudlnt lv¡l ¡tk'd

:o

w¡l!

itudent 1v¡r orornFrcd to

url

r

_

fe¡cher w.t anlnornt to olh
cr¡

rpeqtrc rÊpraceilrnt brhavrgr
lwhrsh

one?

r

¡tudent w¡r told to movr to ¡nother
- toc¡tron

'jtudentw¡t

¡tv!n onc.on.onG ¡trrnlton t,Jetc¡lbe:

th Er:

r.l

?fior lo

restraint or seclusion, please descnbe
the de-escalatlon strategies that
were eftempted by staffr
loom cle¡r lremovc auclrcncel
iet ¡ trm€r
Ðhect to coor down

v

¡

Set hmn¡ lrl'

_

"rr"

th¡n)

ú_'ffered

gnorln¡ (notprovrdin¡ å¡r€ntroß
for ¡sc¡r¡ted behrvror 

-

_

chorc¡¡ for cool down

F¡rlt/thcn

¡romFtrng ure of repl¡c:ment behavror

5tu den

t

rton-aqgressive behavior prior

Student cggresslve behavior prloJ to re5traint
or seclusion:
Student agg

Time

ressive behavior

out:

Srgrnnrng

or.,

durí¡¡ restraint or seclusion:

Cl

05

i¡cins trmr: c1'ZD

¡iairðtlåble. neec ¡cmrnttttatoÍ eEotov¡l (oocum
ent trme/roorovalf

Phyrical r:o¡traínt:

K

_:l¡

,:s

,,v¿r

uslCi

LUL

' lf Juratron

êxceeCs 50 minutet

-

:

_

3rgrnntnç t.mcr

$',oc:ncern¡

l:am

.\ \'l

dercr¡b€

-,lcnccrns.

C¡lV)

tÀJ

Chillren'¡ Contrcl poSttton

:'r¡luðtron, ,í :þy¡¡c¡l r!tttrtnt

.å'

:'¡ ið t'Jrê

Cont¡ol

reEã g¡rent ¡oprov¡1, ,f parent r¡

poSrton X

:ndrng

r¡me: c\

Z

.,¡nsoo¡! pc5,lron
C,

 rttfl ¡nd/ot procêrw

Oi¡mal€:

tc ctþet studrntr'
:¿¡crtt å olFel 'Fluf' €!
place ¡íter tlm e oul wa3 complete:
gescrrtte wh¡t look
->

X

lu d € nt ttltclg! tnt lfwrrontntnt
t?tulned to

i lud€nt

qurÉl act¡vlw tn
StuJent tl¡n¡rlloned to

tbout lnt gllr'vlof
rn ¡ prwett convlfl¡tlon
itudent lnd ¡tail eFtlstd

lvoll t¡31(

td'
5tucent rln¡tneo to 3En'

ll0lr wrln lFt lrOUgSiUdCnt'ttlJrrre0 !!
tîlt:1f3trt¡llY ¡l ¡ :Ëtm

:,1¡if

i iail

$.rl

¡o tne currenl

,¡ccording

J

/¿-rbt\

- tntlF"ntlon
tt revrllr curln3

ô

t;ßrg

gtrett$tt

F?AÍ3IP lfltttllFl
n:tlt ft?rnellY ¡3 I lê¡rn to rEv'lw

r)thC7:

¡

I

clttt'$mt:

d funcrion of thlt behavior?
tBA' lvhal lt th! hvpothe5ir€

pl¡ct' ttr lf¡ov' to docurrtntl
cenrvlof trfltGün! mu¡3 t¡ka
o¡ntcul¡r
tnrr
¡ddr!¡r
nct
13Â dcr¡
t t curtrrrt
¡o o!êr rtttlltton
"
thrt bËhNvlof rt frt¡rntelnrd bY tcc€t¡
¡ntn$on
¡dult
to
¡cce¡¡
-hr t c€n¡vrol rt m¡lntlrned bv
:h

/É-'11 

I

3

lrom tocla¡ rntel3cllon
Clr¡vlol rt fnalnt¡n€o cv e¡c¡o¡

t

oln¡v¡or rt tnatnt¡¡nGd

!''

talhi ol i¡ßn'rtlc¡
etc!Þ! lrom un'prefcnEd

:hlt

to otalur€d ltrml/¡ctlvrt¡lt
cên¡vroru rr¡lnt¡lneo bf' ðgcAtt

rhl!

iÊn¡vror tt

lfllnr!lnQd by !utomôllg retnlolcement

f \å9ff*t5k^+

incident?
match the ABC of this
ooes, this hvpothesit

¡uatt¡l€t wrll ttev tht 3'ml
md hslrucÜon¡¡/ intervlntton
¡oFrogn¿tl
w¿t
rntcwtntlon
out
wol rrvraw lh'
nc!,¡tlvc bch¡vlof' Thc tgam
rn'Y h¡vl ralnforcrd thr

-{'/¿9. Y€1, howcvlr our lntcrv'ntlon

lnctdcnt' AEc d¡ta wr¡l
dor¡ not rerrn to m'tch thl¡
i\ lo, tha hvpothcllt

¡cnedule d

(pleatG

bl

wrll bo
mGrtlnl to rqvtQw th6 FBA
collccr¡d for 5 daYr and I

6ocumlnt trmr and d¡tt ebort)

behavior?
't/hat is the desired replacement

How

O

rel'on¡cpt¡n'

this
leplacement behavior on
are provid ed for Eaching
lnstruction
detigned
rnanv m¡nure¡ of ¡pecially

.jlrnUt:r ¡nd :en'lc! PrOvrdef

Íle l:¡m ..vill nsrd !o mea!

IEP?

reolecentlnt b€htvlor
of senrtcg nme to te¡ch thlt
to ci¡cu¡¡ addhl mlnutt¡

o¡tt:
P¡rent/6uardian Cont act:
:'r9olt ç¡rEl!lt6

studenl'!

qì

ttllt :,mc:I*å!;!N $tthodorcontåsr:
¡,:mrnrttlltol !rlnaturt:

gY:

å ,vrrttln cq!ï
:¿no

of

lht rg0oñ fnu¡l

g¡lrll

Þc

potrm"lrd

to tnr

p¡ttlt/lu¡tdl¡nl¡l

wl¡hln

lhrlt d¡vr of th¡

C¡mul¡lt'¡c toldEt ¡nd tdt'cl¡ton
of tetort toi P3rênt' Studrnl

Servr¿el

¡nctdant.

Ce¡l¿r

@

 qlrrlls

J¡te ol Oocum?nt¡tton:

¡()lV,\

o

Ð

(;f¡Y

t [t i rt Itìt t¡a.f

ßrport Documcnt and Seclurlon Tlm
e€ut Log

Student:
f ¡t€ oi

ng:

tncldcnß

llrrlre _

lirilr

of l,1ctdcnc

?u¡¡tronoftnctdtns:

Team member¡ involved;
'.r/hat rvas haopenrng imm

t/

.¡

pelr

dnt/ar¡umenlrvrrlr

:tud'nt w¡l oan:ld
itudent

_

Studrnt tvtr lrvtn ¡ tat¡ lrvhaß krnd of

crelerred acltvr!v or

rY¡r ¡tkEd io

¡tud€nt w¡¡ told

the ttud ent's problem behavior (antecedent):

wa¡t

to movc tg

r¡rm

t¡*l

ltucant rva¡ r¡orctcd to t¡artrrron

I

_

rarcher w¡r ¡Kartornr to

ituütnt'.v¡t -prom9rEd to ut! tpecrfrc rcpr¡cement
lehavror lwhich

onc?

othe'
r

- lgc¡tion
¡ñoth!r

'¡tud!nß lv¡r
ltvcn onr€n.on! ¡tt!n¡ton
lJ

ther:

Prior to restraint or seclusion,

t

;ìoom ch¡r lremov¡

--

se'm*
¡rofr'pltn¡

Student
-

please descnbe the de-e¡cara¡ion
strategies that were attempted by staff:

¡udtcnc¡l

(ir,,heñr
ure of rcplacGmrnt

iet

a

¡mrl

D¡f

ect to coor down

are¡

ott€rld chotcet

*- {:Íi,itfi;ffi.*:;..Ï:i,ln*.n

lch¡vtor

for coor down

fo

-F¡,rvrhrn

frc Yn

non.oggresslye behavior prior to rettraint
or secluslon:

rcûA/L

Student c ggressive behavior prior to restraint or
secluslon:
Student agqresstve behavior duri0g restraínt or
secluslon:

Iime

out:

3a¡rnnrng

tqj

,,^rr3lV

¡ncir'rt trme:
¡ra.¿ðrt¿ole, r¿Ec ¡cmtntstrator ¡po¡ov¡l
{ oocument ttm€/ðooroval)i

-"\

)l- rE¡

Physical restraint:

-''lo

'

rf Cur¡tron

c

portrqn
-qhirdrln'¡conrrcr
!egrnnlnt !m¿:

Já

.,0

Ccnc:rn¡

_{cncrrns,

\:tamcontror
3
'lo
.1t2-

.+

-

i.r¡tu¿¡on, .i ¡l.v¡rc¡l reitr¡rnt wa! usedi

edr 50 minutc¡ - ne:ct o¡rent 3op¡ov¡1.,l
9¡rênt r¡

po¡r.on

:-nd¡rg

-.anrgort PcS,iton

'1 o"l
rrmrr ntz^

Jerc¡be:

: lnåtUfÊl

a,

 rÊ

-r¿¡ÊflÞ

oth

t¡e

0efcrr

€f 'Flulrrt

wh¡t

¡O

c¡hef

look place

tludlnt¡' rt¡rf ¡nd/ol

prOO'lW o¡mãlt..

¡fter tlmc ou¡ wa¡ completei

'fi^¿¡^

3ludcn¡n¡tcnothtlnvlronmtn!")l_stu.trntí¡nt¡$onedloqu¡tß¡cßlvlryln
prnru convaf !illon
itudmt rnd tÞtl rngr¡ld rn I
ttll
to',ïorr
itlur¡':cd
: ludent
ltud¡nt rtn¡rnËo t0 l'n' Êd' lt$rg
tþt group
t! wort
5

Eudanl'tturrld

tad',1'rl mctt lttñelty

C

¡þoul tne osh¡vtof

-

"rrth

éågsifrret.nlclff¡l]v¡¡':t¡mt'fÊ ,ll\ïcunrnt nttr¿.nllon¡tf¡le$c¡
=
d¡l!' timl:
te rrv'rw ílÂy'âlP lft¿ltlïrl
5

uerl<.

I

¡¡ ¡ rllm

-éé
')!F?7:
to üe current

ACCording
:n6

''hl¡

\¿

c'Jtrlnt iSA.Jcctnctåftd'lt¡tntloenlcu ¡lcehavlol me?ün!mu'tnl.¡placc,'.lebov.toóocuñrlntl
to o€gr ¡ntntlon
ihit bch¡vror r¡ m¡rnta¡nld bv ¡ccGt¡
¡durt ¡$tnaon
rr marnttrnad bv acct¡t to
ceh¡vior

fh ¡!
¡

4-:h

funcrlon of thit behavior?
tBA' rvhat is thr hvpothe!¡¡ert

EÊFavlor

-

loct¡l rntEragBlon
t¡ rÍalntrln16 W Êtctol from

r orh¡vlor tt mðrnt¡tned

îhir

Does this

gY

e

or acrrvltlt¡
¡g¡Fr f rom un'prei¡rnÉ t¡¡hr

tg grcl€íÊd ¡trmt/actlvrtlGl
ien¡v'or rl n¡lnt¡lne6 bv acclrl

t

thls incident?
hypothe¡l¡ match the ABCof
w¡ll ¡tav

tht samt

,le'.ouflnte'vtnllonw¡r.Fp'o9llalo¡ndlnttrucß onaUintencnt'o¡3¡¡¡ atlê3

_f-

Flan'
Tht te¡m wrll rev¡lw thr rerponre

¡g¡¡v¡s¡'
mlY hðvl rcrnforcrd thc nttawl
vet, howevü ouf tntln'entton
will br collætrd for
milch Ìh¡ lncident' A¡G d¡l¡
þ
not
¡ecm
doct
hVpothc¡tr
i ¡o. tho

5

thi
d¡Y¡ and t mtst¡n8lo rgv¡'w

trmc ¡nd d¡te abovcl
rcnEdulc d lplelse 6ocumtnß

deslgned
rnanY minute¡ of specia lly

on
tcaching rePlacemcnt behavior

are

..1¡nuti!t an6 rlrvlcr provtdcl
T\É Ìe¡rn

Pa

witlnrldlom.ettodirculraddln¡mrnut¡¡olslfvictttmc

00,.,
rent/Guardian contacr:

dLL!!

w¡ll ba

a,

t.r,/hat is the desired replacement behavior?

How

FEA

to lerch thl¡

3 tEP?

l¡cËrnlffi bch¡vior

.,n¡¡ \0\oofil4.lerhodorconrecr:
l,lmtnrstrltor tranaßuta:

:,.colt ccftçltle€l
å ,vilnañ

309r, ol rhc reoort
I

g¡trnVNu¡rdt¡nltl
r¡u¡t ot porltÍ!fl?d to tn'

..rrthln tnrcr d¡vr

olthr rnctdc¡l'

¡rd Éduc¡tlon !GrurcÊr CEnler
sluÛ!nt Crmul¡ll'¡! ¡oldE?
¡nc s¡qlrl of rrFott lol P!tint'

@

 L

IÕ

r)Jte oÌ 0ocumentallon:

tO\V¡\ (.'lTY
\r:Íat[ ¡[ttrr¡;l

Ð
Ð

Seclusion Time-O
Grade

Stude
Da

te

,ìt%

t

of lncident:

fêa m members
What

Duratlon

Time of lnc¡dent:

involved

peer

_

Student'.vas glven a t¡sk (what klnd of task?

Student rva¡ denled preferred activity or
Student wa¡ asked to

studenfs

to

was haPPening imm
ftght/afgument with

X

t

ltem

X

,,rd.n, *as

expected to

Teacher wal ãtt€ndln8 to others

transitlon

-

walt

Student was prompted to use rpeclfic replacement behavior (which one?

Student was told to move to another locatlon
Slven

Other:-Studentwa¡

one'on'one attentlon (describe:

.

I

.

-.

Ïik":-*r'*ï¡iÏïJïri::

,Ð-ïü-ì"::" -i:i
set limits lif,

.

.

thenl

lgnorlnS Inot provlolng ¡ßenllon ror escara(eo

oendv

,

\

promptlng use of replacement behavlor

-Student non-dggressive behavlor
L

prior to restraint or seclusion:
o

t)

u

restraint or seclusion:

behavio

Student

out:

Begtnntng rime

tì

enonzm"rl D '

Ll ,?D

4?

navailable, need admlnlstrator approval (document tlme/approvalll

Physicalrestraint:

"Ðr.ru,,,r,,on,

CÐu.

restralnt or seclusion

Student aggresslve behavior

Time

d'wn

)lo _

iÍ onystcal resrr¡rnt',,r¿r ,.¡slcl:

Yes

C',4

x

lo:

t

tf duratton exceeds so mtnutes

i3eglnnin?

.-

r:eed parent approval, if parent ls

It

-/0:2Ò
*,/oP.*, ?!n;l,o"r&f

Concerns

-

lO:zal
Tearr Control Positlon

time:-

Kr.n,pon

- lÞ l.f
Posltion

Ending tlme:

L'jncern¡, ,j¿scrtbe:

;Í'ìr ..?

. ,-

/0 :55_

 .

Desc rrbe other inlurles to cther ctudents. st¡ff and/or property darnage:

Describe what took

\,/

/\,A<

Ð

place after tlme out was complete:

itudent restored the

environment

S(r,dent returned to work

student transltloned to gutet actlvity ln a pr¡vatr work space

task

ltudent returned to rvork wlth ihe

Student ðnd staÍf engaged tn a privðte conversatton abou¡ the behavior

group

student returned to gen. ed. senlng

Staff met informally as a team to revlew current interventlon stfategles

-

-

Staff will meat formally as a team

þ

r€vlew FBA/gtp (Meetlng

date/ilme:

I

othe
Accordlng to the current

FBA,

what is the hypothesized function of thls behavior?

the current FBA doe¡ not ðddrest thls pãrtlcular behavior (meetlng must tðke place, see above to documentt

--

lhls behavlor

ls

m¡lntðlned by access to adult attentlon

Thls behavlor ls malntalned by escape

fhls behavlor lr malntalned by access to pcer atten¡on

from soclal lnteractlon

-

fhl¡ behavlor tr malntained by escape from un.preferred tasks or actlvliles

_

Thls behavior is maintalned by access to preferred ltems/¡ctlvitles

Thir behavlor ls matntained by ¡utomailc rclnforcement

Does this hypothesís match the ABC of thls lncident?
Yes,

our lnterventlon wa¡ appropriate and lnstructlonal/interventlon ttratcglrs will stay the same

Yes,.however our lnterventlon may have relnforced the negãtiv€ behavior. Ihe team wrll revlew the response plan.
No, the hypothesls does not seem to match thls incldent. ABC data wlll be coltecred for 5 days ðnd a rneetlng to rev¡ew the FBA will
be

:cheduled (pleare document ilme and date abovef

What

is the desired replacement behavior?

How many minutes of specially designed instruction are provided for teachlng replacement behavior on thís student,s lEp?
ñlinuter and service provider
rhe tesm will need to meet to rtlscuss addlng mlnutes of servlce tlme to teach this replacement behavlor

Parent/Guardian Contact:

Dar€:

T!me:

Réport completed

Method of contactt
Adminlstrator

A w¡llten copy of the feport must

postmrrked to rhe pãrent/guardianl¡l within three day¡ of lhe

Send coplo¡ of report to: parsnl, Studrnt cumulatlve Foldqr ¡nd Edusðtron

1Ð

seßlcls clnrrr

 -"Jte

oi Documenreuon:

q t\

lo\v^ (:¡'tY

¡D

Y ltt¡rt

tilìtl¡t'l'

lncident Report Oocument and Secluslon Time-Out Log

)
ituden t:

Surlding:

tt: ol lnc¡oenti

1/rr /rç

-:¡m memÞers

ln,rolved

:

'':e

Grade:

of lncrdenu

f&

l: ¿ô -

l:3ß

ø.

ld

--rr¡rron cf lncidenr:

,'Jhãt ,,vðs nappentng immecjiarelv prior to the student't problem behavior (antecedent):
gnr,r¡rgurnenr rvrrn

:L-

oeer

itJJên!

-

:r¿L:ent'.vå! cented oleterred acttvtty cr ,lêm

wått

_

¡ tatk l\rn¿t krnd of rrrk?

:luüeñt wðs Ex

d

r

to trlnsrûon

jtu'lent'.vð! oromoteo to u5ë toecrilc reotåcement oenavror lwnrcn one?

_

_

-

_

'(u\.rent'¡/ai (old t0 fnove to 3no(nef loc¡tlon

cuüen! 'lr3r ð!ßect to

wð5 Erven

i:l'er:
-::.,cent.'va¡qlvencre.on'one¡tÌenr on ue!crloe:J
.
,
. .,

,

,

--

,).i9r to restrstn( or secluston, please descrrbe the de-escalatton strategreS that\rvere ðttempted by staff:.

\_ì
-) V'/

,
-!1

:rJúfn

  êtl lremove auorencgl

_

renr

/

:*l'rn'(3

rrf, :l:

.:::rlct:rg !!¿ ù! r¡t:¿c:ment

:¿( å ¡rrnel

:,r¿ct(o cool down

ðreð

,JÉe¡edchorc:l ioÍ ccJl Jown

¡ttentron ror:scarareo behðvrorl
,"or,"g [not orovrorng
-

renùvtot

-:irsrlthen

.)t-:er:

::ì,-ldent non-oqgresstve behavlor prlor to restr3lnt or secluslon:

(

itu,jent

oqqressi'te'oeht,¡ror onpr to restraint or secluston:

jtudent

aqgress,ve beha,rtor dutinq

restr:int or Seclusion:

ô

\¿., cV.

:'me out:
r,' åzàr,å

b

le,

r¿tã

3*grnnr¡¡
¡Omrn

lh'¡sical restrarntl

r,-a:-f2!l¿

!tl¡tcr

i^drrgrrrre:

l:1ß.

':f cur¡t:onrrcseã!50mrnur:s-n:edoarent¡ogro,/¿t. ic¡rentt¡

aooroval l ðocLtnent ì"'n¡/aoprovalÌ

rt

ic

V

:u'Cren's Contrrl Pcsrt'¡n
3cgrnn,ng

'r

)

i'¿':luatrcn,

i:-Ìt

c¡l rêslr¡rnt'.'/43

':5Êd

¿

r:in:irn5 _

-; ¡m C:n:rof âo3lt on

,,,rr 1"25

l:trter¡s, Je5cíb¡;

lnrJir:g

_',t'tpati

rrrre: l" Zþ -

Pcsr:'cn

 ,¡r{eJ{ob,

\

{ann¿aFr

þ

rô

pfoceftY damaqe:
¡be orner rnlufiee to ¡ther 3tudcnts, ¡t¡rf ¡nrJ/or

.þ-¿'

;rrbe what took place ¡fter ttme out was cornplete:
.J
rSf

L-iro"n,

*t.roan, rr,urn.o,o

rvorr

l:¡ rf

met rniorrFallv ¡s

stuJent tr¡nsrtloned to quret ¡ctlvrlv ln ü prlvate work soace
;rr,Jent ¡nd starf rngaged rn a prrvate con'/ersatron åbour the cenavror

tasl

!tu.JËn! f eturneo to worl( wrtn lhe

-

l-

rêsloreo rhe envrronment

group

)

;tudent retulned to gen' ed' leçlng

¡ team to levler¡/ curfent lñtêln/€nt¡ofl Strategles

jtatt'¡1.¡r rne¡¡ ior¡natlv ¡s e le¡m to levlew i3,r/alP lùleetlng datei time;

:ording to rhe current

what ts rhe hypothesi¿ed function of this behavior?

FBA,

,a" arr,ant ÉðA,JcÊr nor 3dorest
_

-*,t

Egñ¡.,o1 It mðtntAtneO bV ¡CCe55 to ¡dult

Varrr!eFavtor

_

(o documeñtl
¡nr¡ oanìcutar oenavtgr (meetln¡ mus¡ t¡ka place' lee åoove

15

-\¡t

attentlon \./

cenavlor

15

mðlnt¿lneÚ bv acc€59 lO Ueef altentlcn

11.

malntalned bv escape trom roc:¡l lnteractlon

-rt!s brnavtor tf rn¡rntarned by escaoe irom un-preter?eo totl(s Or'¡ctlvl(let

û
Þ'

-.1l5ce^3vlol¡flnå.ntðlñ€oovJcc.'5to!]fÈ'efrec.ten5/tctlvltleS
-it,s :enávror ri mðrñlllll€d ov ¡u(om¡tlc retniorcement

-¡es thts hvpothesls

match the ABC of this incldent?

i5. ':,Jl nleÑent on wåi ôpplopftatê

_

ðnd

lnltlucllonãl/llìterventlon strateglar wll¡ f tav th! 5ame

..ú.

ã-r,"o

,.re tlyua(nerr, uce¡ f.o! ièem ¡o irðlcn ¡n:5 r;'rctüent. ,Å5C l,¡t¡ "vrJ
I ole¡rs€ ãccument ltme ¡nd d¡te aoove)

!e

:31;:C¡eO ler 5

i r'utei and re¡rlce clov

-.e

replacement behavtor on lhrs
sDectatlv desrqned ins¡ruction are provrded for teaching

cef .

1¡3rn.¡trl n::d

r.o

.

, .

 ?eet

lo

J:3CUSS

:1¡ç¡t/Guardran Contact: t¡tE: .q I rt
tecort :irrc:¿!3d

drvs lnc t :eellng tc 'et''r"e tne tlA'r¿ill ha

\l

'/h,¡t ts the oestred reolðcement benavior?
{ow rilanv fì.rnute' oi

rOdlnq m'nules

)

ít1€leðmwlll rev¡ewtheresoonscol¡n'

r,lr,ìe..vevêrûurrntenrentronrnav.ravererntorcectl"enegaïv€oenavrof'

student's

tÉP )

ol sen¡'l: !lne !o :eecn lh't rtolacen"€nt tenavrol

/tS ','., -L$-

r,rernod or tcntact

¡dmrn'strl(or

bv:

I

.vr

cen csoY
:Èr,at

O,

lF! r€tort mu¡t:ê ocilm¡fked to ìne o¡rent/iui¡fo¡¿¡nt!l

racter of rrÞott

:{l

e.rranl, !¡'Jtsn! Cuntrl¿¡' !?

fo-ler

1nd !'Juc¿t,on 5enrlcel

f,¿¡lrr

(Q
Y,

 J¡tt

oi oocumentûlton:

l

¡()ÌV,\ (:l'¡Y

o

Ð

{ llr¡rl t  \ltÍl.r

dent Rqport Document

5tudent

lding:

I ate,ot lnsrdenr

feam

;ifie

6rade:

S

of tnctdent:

rn

happening immediately prior
to the student,s pro blem
behavior (antecedent):

rtarrum enr

wr

rh pr er

_

,

itudÊnt war ¡¡ven ¡ t¡sk
ftrhðt krnd of t¡lk?

-Yju¿enr re¡r dlnrld preie¡red ¡cttvtty or ttrm
5tuden¡ lvas e¡Dsc¡ed
ltudent
wa¡
asked
to ìvatt
_
_ itudrnt rv¡s -promptect to
itudent

-

{\\

Ður¡tron of lncrden¡:

members involved:

'.Vhãt rvas

/r

on Tlrne.Out log

rvet told to move to

to transrrron

fercher w¡t ðttcnoing ¡o
othe6

us¡ ¡peCrflc rrpl¡clmenr
b!hevtor (whlch oncl

-

¡nother loc¡Uon

5tudent rvar gtven 0ñ€.oñ.oî!
¡t¡enilon tdetcr¡

r)th€r:

-

prior to restraint or seclusfon,

f

please descrlbe the
de.escalatlon strategles that
were attempted by staff:

;:î;,,,movt'udrencr'
áro^pttng

Ðirect lo cool down

;,1ï'''':'

,gnoflng (not
provrdlng

ar!¡ _

.

¡ttrnilon for e¡calated behavrorl

ur€ ol replacement behavtor

_

Oflered choicer for cool down
Fírrt/then

Student non'oggresstve behavíor prior
to restraht or secrusion:

t-

aqgressive behavior prio!,
to

or secl

Stud ent aqgressive behavior durínr
restraint or seclusion:

ïime out:

eg¡nn ,nr,,ao,

Ql{ ?

.

inctngrme:frf

¡navarlable, neeo ¡dmtnts¡rator
apþfovel ldocument trme/aporoval);

Physícal

restraint:

_

ito

_,ihrldren,¡

'

Control

lf duration €rceeds 50 mlnuter _
need parent aoprov¡ , parent
tf

po¡ttlon

_

3eginnrngor.,
iyalu¿ ¡ron, ri phy¡rcal rertr¿rnt,.vði

used:

]i

llo concerns

_

ieam Control po¡tt¡on

?.

Ib_

rjcncerni, describe:

endrns.me;

)(-

ts

,rrnroorr polrtron

*)t

:;jneture:
r

1l:

 --L-- ttud€nts'
'o¡'¡¡'ñrc
rnlulle$ to cther

othÊf
:¿gcf tbÊ

prooerÞf,iütfo:

lnd/or
¡nd/c

"tel
"t¡rl

tirne out wai
w hat took place rfter
e.
b
De:crt

StuCJenl'eturncd

: (Jlf

!o

wrth thl

rvrrl

tt

revlÈw curlent lntervËntlon

tc revr:w F¡A/8IP
mert iormallv ðt e team

rvhat
to the current FBA'

-...ó, ,rrrvrrv

rn a

p.vot!

r¿

o

fetufned lo ¡en' sd' tettlnt'

gfoup .-sludrnl

¡)thel:
Àcco rding

.

"vork

rFttlllolrnarlv ¡¡ ¡ :'am

staif

complete;

tlraleElts

l$e€tlnt

dele'tlríe:

I

'

of this behavior?
i: the hVpothe¡ized function

to documentl
takc placê' lee ¡'oavr
behavlor lmetthf' rnust
partlcular
thlt
no! ¡ddrest
îF e cufrtnt tlA does

-ihit
-

' -hi¡

brþ¡viol lr rnarntlln€d

íhtt

blh'Ylorllmllntalned

.

bV ¿ccels

toådul!¡ttentlon-fhitbrhavrolìtmarntalnedbY¡cce:rtopeer¡ttentlon

¡nleradlon
bv elsape irom ¡oct¡l

ta¡h¡ ot ¡¡qt*llle¡
bv esc¡pe ftom un'preferrcd
oen¡vror ti tn¡tnt¡tned

This ben¡vrol lt melnt¡lned

bY

¡cce:l to glelerrcd rterñl/acßtvttte¡

rhlg blh'vlol ll melntalned

bY

¡utomatrc rctnlorcement

match the
Does t hls hypothesit

ABC of

this incident?

w¡r ¡pprogfl¡te ¡nd instfuctl0nal/lnterventton
our rnteNrntlon

semc
ttralegler wlll ltËV the

&

plan'
wrll review the reiponse
bthavior , fhe te¡m
neg,.trvr
thÊ
rcrnforced
rnteflentron may hrvc
Y et, howqver ouf
collcctedfor5daY¡and'mrrtlnstolevlewthcFBAw¡llbe
ABC d¡t¡ wrll b¡
t,
to match thlt lncldenl'
sclm
not
doet
hvpoth6¡l¡

'/Ê9,

tlo,

tha

trmc ¡nd d.t€
scneoule d lplealt documrñt

abovc)

ti

behavlor?
deslred replacement
',r/hat is the
eclal

of
How manY minutes
:¡íirute¡

I EP
behavior on th¡s student's
ed for teaching replacement

ano leNlc€

Tht

ðddlng mlnuter

t!!m wrll need to ílett

Parent/6uardlan

0¡tel

Co

:eport completec,

thls replacemenß behevior
n ice llme to te¡ch

rrr.,.LJLP\tr\'l

ethod

o

f

co

nlact: v

¡dmint¡trAtOr rrgnature:
bv

¡

.vflltgn coFv

¡nctdlnl'
wr¡hin thire d¡vt of lh¿
to thr p¡rÊn t/guardi¡n(r)
b!
oottm¡?r'd
of thc reoott rÍu¡t

toi PtrEnt' Studênt Cumul¡liv!
:¿nó coplca of leport

Cenler
foldêl ¡nd gduc!llon S¡rvrce¡

@

 rl

.-

a

(

l.

1OW,\
Y ll¡hll

¡te o¡ 00cumentatton:

(:¡'¡Y

lltlt¡a'f

lncident Report Document and Secluslon Time-Out Lo g

)
I

tudent

: Jtg ât lnçrqent;

-:¡m rnemoert

3urlding:

,Sracte

'' re of tnctdent:

I ¡ rltron cl lncldenr:

/ë

.z'

,- ,, {¿

5

rnvolved:

,'/hat '¡¿¿s naopentng rmmediatelv prior to ¡he studenf s proolem behavior (antecedent):

X

gFt/ãrSurnent rvtln oeef
::'Jr.:Èn! w¿¡ cented orelerred acilvrty
j

_

_

(u\ren! w¡9 ùsxqo to

w;tr!

cl

_

;,rc.nt w¡r irrven ir

,(em

!turje

iruoent wðs ofomofed ro use ¡pecritc teotðcement oenavtor l¡rntcn one¡

i:u':ent',v¡s qtveñ one-on-on€ ttientron roefcnoe:

ìFe r;

,rrior to restrltnt or 5êcluston, please descr¡oe the de-escalatton strategtes that were atlempted by staif:.

O'Ð

¡ ¡rmet

trJGñ i'êåf rråffiOvê ¡UOtenCel

_

;¿t

i.:l rnrtt

\/
-s

t'or,rg tnot orovrorng ¡ttentton lor

ry

rrl, :nenl

_

-'rf åct

to cool down

åra¡

ddered cnorçej iof cool Jown

åscalereo Eehðvtorl

x-

o,rrrr,nan

:i:l¡Clirf J!¿ü!,':tiðCernentC3n¡ìrrOr .iì¡er:

:f udent non-aqqresslve behavror orlot tc restrarnt or secluston:
I c,,

j

tu'j e nt aaqresstve

ra¡nt or seclusron:

to

behù,¿ror

tD

r
j tudent

lr",41{

:^drrg !rm€: 10.'7û
¡.ì¡7âtlâblê.r?Èã:!cm n5Î ¡Icfaoofoval{rocunent:"me/aoprovat i
3agrnntng

:hysical restr.:int

r.

ic

-

, ' 'f jur3r;on .:(ce:oi

50

-' .) i'rriu¿!rin.

i:r,¿;,:¡t r:5lf 3tnt,,!ãi r.ied:

nrnurl¡ - nted par':nt ¡sorcirat,,i cårenr

Pr5rt,tn _':!mCi.:Irol

.-'i5

-lt'l'Cren'¡Conlt:l3*grnnrng t¡r¡?:_
'\_

^ll

l.o,.

oqgresstvg'oeha,¿ror durinq restreint or secluslon:

-'mê oul

t:

n.a-l¿-

',? t::fì:?tñ!

{::ncelnt, J?lctrba

-

ir-r( r'?:

,s

cos,lon _t'::"spor!¡c!,:,cn

:n,JtnB [r¡n¿;

 I ¡

.L,

¡e otner lnlullet

þ_r

what took place ¡Íter tlme out was complete:

nbe

:tuoent

.

/@

procerw d¡rna8e:
to other studenls, gttrf ¡n'"J/or

f

ertored the
ro

þau oan, relurneo

prlvale lvof k space
stuJ€nt tr¡nsrtioned to qule! ¡ctvrtY ln a

ênvlfonment
,.vof

r

K

r¡3r(

about the Þel'avr.r
iruãent and starf an'âged rn a prlvð¡e con./erlatron

)

- itutjentrerutnedtoworkr{rrtnth€group
j'.¡rf

-

lntedentlon rlralegle¡
-.<tudentreturnedtogen'èd'sertlng
rnet¡niorrnatlv ¡s r team to levlðw curlent

it¡ti',v,rrrneÈtlolmallv:r3¡te¡m!orevrewt3'¡iAlPlívte€tlngdateilimcl-l

ordingtolnecurrenrFBA.rvhatisthehvpothesi¿edfunctionofth¡sbehavior?
::-e cuíEn! tlA itce¡ not 3dore¡s

!,n15

plðce' !eB aoove lo documentl
cenlculal cenavlof {meetlng must take

m¡rniarneo bv ac:ett to rdult

a(entloTã-

-.^,Í

€eñ¡rrror

;'att

socral lntelactlon
b¿navtor ¡¡ matntatned bv ¡sc¡pe trom

15

-\ir

-

'rìt5 bgnavtol lf tÍðlntalned bv e¡cape irom un'prererred

-

-1r5 Cêfr¡vlof rt lnàrn(alneo ov Jccêst ¡o olelelrec ìtemt/¡ct¡t/t¡le3

--

-ir,s !enavlor

l9

atrëntlcn
b€navror l5 marntalne{t bv åcce53 to Pe€f

ta5k5 of'¡clltJllleS

û

b-'

mðlnt¡lneo ov ùutomåtlc rerniorcemenl

of this inci{ent?
oes (his hvpothesls match the ABC

¿'
fa

.*r,.ru,

stâvthesðme

)

",.^an,,onwåiðppropnataandrnsíuctronar/[rtefventlonsllaleglegivtil

.-,e7,lc..qet./erouflnten,eñt!o¡¡¡¡r1nôV€rilntorcedthenegallveoenavlor.ileteðmwlllrevlÈwthefesoon5eq an'
h9
..\)...iervrjutne515ürrÈ5r\Otréemio,li¡tcntn:írncrcen!. AËcJ¡tJ'¡r¡l re:Jri:c,.gdlor5cavrllnl:l-eell.g!c'?v'?l"rnãiqa'¿Jtll

liil-,,.o

I

olease oocument

ltr¡e ånd dste åoov€l

,-{-

.'/h.rt ts the oe5lred replacement benavior?

row rnanv frrnureS oi
.'l t:tJtes

ãnd

5elvlc¿ clou

-.?

ri¡m.,,rt¡l

: ¡¡s¡t/Guardlan

l,¡

tL-

provrded for teaching replacement behavtor on lnls
sDecrallv desrgned instruction are

s'-

udent'5 iÊP)

i:el

r:ec lo niqet !o

Co

J:5cJss rodrng m,nuler

C¡te:

-¡rìe:

oi

sen¿,ce

genavrol
trne to :!3cn rhis reolacement

+iil-ï[S

!.!¿?-nod

ol t¡nt¡

ldm'nlStrltOr

?,?port cirrc;¿tÊd bv:

¡ rr'l:tn

a¡oV ot l¡Ê re

SlSn

enl.

it :e oasrm¡rhed to i¡e 9¡renll

Þ¡rrn¡, <udËn! Clrñl¡l¿lve
:¿¡.J c?ile! ol'ecorr lo:

to'ler

rnd

r{
v'
\

 /'

DJte of Docurnent¡tlon: L

lO\V,\ (:¡TY

rÐ

lnclde

Student

ilding:

Date of lnc¡dent:

Team

and Secluslon Tl

Rep

Grade:

Tlm€ of lncldent:

lYs

Duratlon of lncldent:

members involved:

What

ent

¿utctlsL
sitlon
Student was asked to

walt _

_

Teacher was attendlng to others

Student was prompted to use speofic replacement behavlor (whlch one?

Student was told to move to another locatlon

_

5tudent wa¡ Blven one-on-one atlentlon (descrlbe

Othe

Prlor to restralnt or secluslon,

,,fl..--

Room clear (remove

please descrlbe the de-escalation strategies that were attempted by staff:

audlence 

t¡mer

0lrect to cool down

area

Offered cholces for cool down

lgnorlng (not provrdlnB attention for escolated behavior)

set llmltr (lf, lhenl

X'l)l,oto,lng

Set a

Flrsr/then

-

use of replacement behavior

t*asu frr heþ
Student nonloggressive behavibl priòr to restraint or secluslon:
Student oggresslve

nt or

to

5tudént oggressive behavlor durine restrai nt or

Time o

Eesrnnrns,'r.,

l

0l 3'l

ron:

i lf duratlon exceeds

Ending tlme:

S0 mlnutes

-

need parent approval, rf parent ls

unavallable,needadminlstratorapproval(documenttlme/approval):

Physícalrestraint:

llÐ _

ChilrJren's Control

Yes

'-$Ë,ral,.,.it,c,n,'i

orTsicrl'estrarnt',v¡s u:¿rJ:

{',

o

Position

lBglnnlng

Cqncerní

.-

r

r:am Control Position

(¡me:--

r-ct:cerrrl, ,J,:scrlbe;

-

'' ll r.¡'

Énding timei

lc:3ç
'{rrunrport

lc;1\

Poslt¡on

^.

 De

sc rr be other lnluries to o ther rtudents, stoff and/or propertv dltnage:

Describe what took place after tlme out was complete:
restored the

Ð

environment

Student returned to tvork

d-

task

Ç/*
student l'eturn€d to work with the group

ltaff met informally

as a

Student transltloned to qutet acrlvity in ð prlvate work space

r,roant and starf engaged in a privåte conversation abour rhe behavror
Student returned to gen. ed. sênrng

team to review current lnterventlon strategle'

Other:

Acco rdlng. to the curr€nt FBA, what

ls

the hypotheslzed function of this behavior?

the current FBA does not address thls particular behavlor (meeting must take place, see above to document)
Thls behavlor ls malntalned by access to adult

-

attentlon

Thl¡ behavlor l¡ matntalned by access to peer attentlon

fhls behavlor ls malntalned by escapa from ¡oclal interactlon
behavior ir malntälned by escape from un-preferred tasks or act¡vitlei

.-

Thls behavior ls malntalned by access

to preferred ltems/actlvltler

Ihis behavlor lc malntalned by automatlc relnforcemcnt

Does thls hypothesls match the ABC of thls lncident?

,:{t, P.Yes, our interventlon was approprlate and lnstructlonaUlnterventlon ttrategles will stay rh€ same
ì Yes, howeverour lnterventlon may h¡ve reinforced the negatlve beh¡vior. The team wtll revlew the response plan,
No, the hypothesis doe¡ not seem to match thls inçldent. ABC dðta will be collected for 5 days and a meetlng to review the FBA wlll be

scheduled (pleare document tlme end date above)

What is the desired replacement behavlor?
How,many minutes of specia lly deslgned instruction are provided for teachlng replacement behavlor on this student's lEp?
futlnutes and sen¡rce provider
The te¡m will need to meet to dlscuss addlng mlnutes of servlce tlme to teãch this replacemcnt behavlor

Parent/Guardian

Co

0ete:

Method of contact:

Report completed by:

Adminlrtrator signatufe
A wrltten copv of

report must

postmarked to rhe parent/guardi¿n(s) withln rhree d¡ys

Send copler of report tor Purent, s¡udsnt cumulatlvo Foldcr and Educsrlon serylcrs ccn¡er

,Ð

 l()\\r.\ (:rtY

Ð

o

Y ll¡¡rl

llttlfla'l'

ent Re port Document and Secluslon

5 tudent:
D.¡ta

dlng:

ct lnctdcnt:

Íirl'e of Inc¡dent:

Jurðt¡on gf lnctdent;

1.eam memberu involved
t¿Vhat was happening lmmedia

_

g
X

t'ght/årgumGnt wtlh

to the student':

peer

_

Studrnt wrr ¡lvrn r tash lwhtt klnd of t¡rk?

5tudent wat drniad prcfcrrcd .ctivttv or rt€m
Studcnt wal ¡¡ltcd to

w¡rt

be

_

tr¡nsrtron

Student w¡r a¡plclcd to

_

r.ach.r w¡r ðnendtnl !o o thcr¡

Student war promptcd to urc ¡pccltlc rrplacrment beh¡vror lwhlch

onrl

_Studentwårtivcnona-on.onc¡tten$on(de¡crlbe: ...

.

-,

I

-,

Othe?l
P

t

rlor to restralnt or seclurlon, please describe the de-escalatlon stratetles thal were attempted by statf:
Room cls¡r lrGmova

å
X

5etllmiu

¡udience)

lif,thrn 

9Èt

X-

¡

timrr

Dlrect to cool down

are¡ ..'-J(-

lgnolnt lnot providlng ðtt!ntron lor e¡c¡lated beh¡vrorl

Firrt/then

-

orornotrn¡ ure of replacement beh¡vror

Student

Offered cholcc¡ for cool down

non-oggressive behavior prior to restraint or seclusion:

v\\inn
stT.fúrnri\"rl
-Urcrrtinr
I
lt
I"
9,

tudent
Student

ror onor

or

usjon:

ô

aggressive behavior durinq restraint or seclusion:
I

t.

Time out:

BeglnnlnB

unavarlable, need ¡dmrni¡tretor

Physical restraint

ttmri I : 5Ô'
egproval ldocument time/ålprov¡l):
Ending

XNo

It duretton e¡ceed¡ 50 mrnure:

wa¡ ured:

-Children'¡
l,lo Concernt

porltion

geg¡nnhg

r

s

.

-l:lm
time:_

P?5¡ttor

Control Po¡rtion
:nd¡ng ttme:

-l'¡n¡pon

Concern¡, d¡¡cnbe:
5lgnaturer

Õ

need parent approvrl, rf parent

.

Control

-Vrr

'

l'r¡'

-'-

 !:u dÊnr fêÍcrrd

f ¡_

thG

-i:udenr rerurneo ro work

'u
')
^Ñ

!tucent rlturncd

prlvatc lvolk tpece
studant lf¡n¡¡tloned !o qurÈt ¡ctlvlry in a

lnvrtqnmcnt

sl{Ént ¡nd !t!*

rark

to work rvrth

lhr Sfoup

rngaged rn a p.vet€ converse.on about the beh¡vlor

2'q!St'acnt rlturned to grn' ed' :entng

o

j)-

lntÊfvcntlon ltl¡llBl3l
!:¡f f met rnform¡tlv ¡t ¡ te¡m to revtcw currunt

5t¡ilwlrl'..tfo,,n., ,¡t¡tlemtofavlewFBA/6lP(rttÊGtln:datc/timG:l
.Jthaf:

According to the current

FBA, what is the hypothesized functlon of

./-hirbeh¡v¡or i, malnt¡rned by ¡ccer¡ to adult ¡nentlon

fhl¡ b¡havior lt m¡lnt¡¡ned by accur to

.y/

Íhlr

beh¡vror

it m¡intarnqd

bY

thlt behavior?

pe€r a$entlon

?lc¡pc from un'prelerred t¡¡k¡ or actllllcl

fhi¡behlvrorl¡mlint¡lncdbY¡ccc¡¡toprtftrfedltem¡/¡ctlvitlrt

ihl¡

b¡havrol

it malnttrncd by rutomrttc rcinforcrmçnt

Does þis hypothesil match the ABC of this incldent?

-

v

/

yer. ou, tntrfvrntlon w.¡ ¡ppropflate and lnrtrustlonaulntcrvcntlon ¡lrete;lc¡ wrll stry thc ramc

wrll br cotlected lor 5 day¡ ¡nd
rhr hvpothr¡l¡ doe¡ not srrm to ñatch thl¡ incldent. Agc dar¡
'o.
scheduled lplra¡e documcnt tlmc ¡nd d¡ta ¡bovel

\^/hðt is the desired replacement behavior?

fitS

tt

rft

rf\ -tð s n$i,L¡)g l"
gre

ned instruction are

Ho.ar many minutes of sPec

t mcltlng to revicw

thc FBA

,ñ cc.€

ll¿ü.*t

nt be$avior on this

will be

o

r ),\

student's

t€P?

wl¡nulet ¡nd tefvrce Provtder
The tËðm wtll need

to meet to

ñlethod of cont¡ct:

Pa rent/Guardian
¡

add¡n3 minutc! ol ¡crvicc t¡mc to ttach thl¡ repl¡c¡mcnt bch¡vlor

lï\ * €r

\dmlni!tr¡tor rlgnature:

eport completed

I

wntten <opv of ¡hc

to th! p¡r¡n1/8u¡tdl¡nl¡l wiÌhin thrr¡ d¡v¡ ol thr lncidenl.

gend coorc¡ ol report lol P¡rent, Studant Cumul¡lwe

fold¡r ¡nd EduC¡tlon 5eruic¡¡ Ccnter

&

 f¡¡e oi Do(umentatron:

o

IOW¡\
Y ll¡hrl

tl

I

(lflY

all¡l¡la,rl'

r

lncldent Report Document and Secluslon Tlme-Out Log

)

Buildlng:

Studen

-

l¡te oi lnctcient:

\ã.1

6rade:

Íirne of lncrdent:

of lncldenr:

Tea i'n m embers involved:

',Vhat was happening immediately prior to the student's problern behavior (antecedent):
: ght/araument wrtn
:t

;tudent war asxed to watt

_

icutjent

Prior

rvas

itudent w¡s

to

trrnrrs lrf,

,

S

tudent was expecred to transrtion

-

;,r¿"n,

Teacher was lne ndtng to

-

was promprect to use rpecrflc reotacement behðvror lwntch one?

ath"r¡

#Et5l0leeS

n

one'on-one ¡ttentton tde

restratnt or seclusion, please describe the de-escalation strätegies that were attempted by staff:.

J

-:er

Y

rtam

told to rnove to another loçatlon

f oom clear (remove

n-

itrrdent wa5 glven ¡ ¡ask lwhat klnd of task?

,.¡ e nt wa5 oenre d oreferred ðcttvitv- or

,

ü

peer

auotencel

tneîl

;et

a

¡rme¡ J-

)rrect to cool down

area

'Enonng (not provrding aaentroll for ercalðted

.;rtrnptrng use of reolðc€ment behavtor
-

behavtorl

rf

Y

tfered chotcer for cool down

,,.rV,nan

i)!her:

!tudent,non-aqgress¡ve behavior prior to restraint or seclusion;

õo\eflmrftn
.J

\nrcl\r
J

3ludent oqgre ssrve behavlor g¡!g! to restraint or seclusion:

5tudent aqgressive behavror durinE restlaint or seclusion:

m
:valuatton,

)

rf chylrcal restrãint r,ras u¡ed

f

Besrnnrng,',-n.r-tlþa
,\to

Concerni

t e1:\o o\:an òu:t- o.ñÞn\ read\ 'õ\r\

indingrrrner

F:5tl

Cancetnr, descnbe:

qn3ry bo¡r

3ignature:

snut

ogcrin - Q:\\

Rå*SìüReovnrn*

 properq damage
be other rnlurlet to other ltudEnts, storf ¡nd/or

nbe what took

place

r

¡tudent

rEstored the

_

iru o ent

returnect ¡o

envtronment

wor[

task

Student trans¡tloned to qule¡ aílvìtv ln a prlvale work space

-_
J-

itudent a nd statf e ngaged

- llu,Jentreturnedtoworl(wllhthegroup
- it.¡ if

rn a

pnvate conversatron ðbout the behavlor

Þ

Studentreturnedtogen'ed.retttng

rnet iniormatlv as å tgam to revlèw cufrent lntervenllon slralegles

;tarf

wril meet iormarlv a5

a

tgam to revrew taA/ðlP lfvleetlng da(ei

time:-)

to the currenl FBA, what is the hvpothesized function of this behavior?

ording

_ :n€ cuÍent
_ lhr¡

ÉðA iloes nor adorÊs!

ce¡avior

*

thts paßrcular oehavtor (meetlng mu¡t take Dlace, see ðoov€ to documentl

marntarned bv access to aclutt

attentron

Thi¡ behavror

îhi¡

benav¡or t: matntatned bv escape frorn ¡ocial lñteractlon

 

;,.t,:

benavror

rg

gr ôctlvlllet
marntarned bV escape lrom un-preierfed tasks

_

;htÉ eeF¡vtot

19

marntatneo bv access ¡o oreierred ltemg/actlvltles

;

o

¡íter time oui was complete:

rs

matntalneci bv ¿ccets

lo peer attentlcn

Õ

-'htssehavtofl!malnlalneclov.¡lJrorratlcrernlorcement
,es this hvpothests matcn the ABC of this incident?
"¿5. ,tut r.'ìtervenuon wðs appfoprlate and lnslfuctlonau¡ntervenllon strðtegleS w¡ll stav the same

_

)

.t,,-s,howevet our rnteñentton may nave rarniorced the n€Eauve'oenavtor. fha team rvtll revtew the r:soonte olan.

¡ro. (¡e nvootneSri r]oes not leem to mätch
leouled loleðse ctocurñènt tlme and d¡te aoovel

rhrs ¡ncrdent, ABc

,J¡t¡ wrll be :ollected lor 5 d¡v¡ and ã r¡eetlng to 'evrew the

FBA

wrll be

-

rhat is the desired replacement behavior?
nt behavior on thls student's IEP?

ow rnanv minutes of speciallv
lrnutê3 ilfld Servtgc ofov¡del

ihe

behavlor
teàm wrll need to meet to àrscu¡¡ aoding mtnutes of servrce tlme !o lesch th¡5 reolacement

¡rent/Guðrdian Cont

ìioort

cornpteted bv:

ts

"l -'3O

uerhod of conracr:
mrntstrãtof

ti

gnature:

¡he parent/tuardiðnl!l

lenct ccote¡ of teport to: Ptrenl.Student Cum'¡l¡¡rve Folder ¡nd

@

 -',

q r5

Jie oi Oocumentatton:

l()\V,\ (:t'tY

,9

lncident Report Oocument and Seclusion Tîme-Out Log

)
itudent:

ilding:

l¡¡: ol lnc¡oenç

6racle:

l' re ot rnctdenr: lCI

: OO - /{) i I S

/5

t¡r¡t¡on ol tFcidenr:

¡w.r^

-:¡m memoers rnvolved:
,'/hat r^/ds naopenlng tmmediately prior to the student's problem behavior (antecedent):
gnt/årgurnenr r.vrtn

oeer.

::'Jdgnt wår oenled oreterrrd ¡cuv¡lv

-_

:

(uéenl w¡s ð¡Íed to

'rudent

_
_

i

.'vaS

l:cent

,.val¡

!olct to n ove

'.vðr qtt/Ên

jrJJên!

_

_

or,(em

'.v¿lr

-!!

glven

¿

tarL (wnðß krnd ot

ca¡k?

- Q\a55rooazr +? bá"*læ

I

:tu,:ent wð5 exo€cled to tr¡ñsrtron

i¿ ¡cn et rv¡s

la

ituoant war oromoleo to use tpectltc teotacement cenðvlot t,¡¡nrcn onel

lo ¡nolhet toc¡i:on

cre.tn-one 3nen(ron I uercrtce:

iFer

Cr

,).ior to res(r¡tnt or tectuston,

ry

,olease descrroe the de-escaletron strategtes

rrJGrnlê3f tf¿move¡uorencel

l¿¡

rn

t¡

rri.

_:¿(ånmet

:l:¿nl

_:if?cttocool

thatwere attemÞted by staif:.

oownafe¡

,jf¡redcnofcSrtorccol .:own

.;'orirg (not orovtornB ðttenlron tor rscalareo Eehðvrorl _

ãirttlthen

-.]:.?incUrqJ3¿c:¡.,l¿cåmentcen¡vlorjii.''
::i'-ldent n)n-oqgresslve ôehavror pnot to f estratnt of secluston:
t

jtuüent

'j

oeqtessve tJeha,¡ror

gMI ro restraint or seclusron:

lud ent.oo gress,ve beha,¿¡or dud¡q restr3lnt or seclusion:

r'.\

IA

t'me out:

,,,n.r. lO : 03
ar.c¡ng lrrTs: lO I t 5
¡'i'/.trrå'o!ê.f¡eg3om nsir¡(cl¡oorovaIl:ocr,r:ent::¡n /åoproval ,
3:grnnrng

:h'¡5icalrestraint:

/',"

{f9

:h' 'lren'5 Cantfzl

-

Q: \)

:'/¡'uåtrrn, i 1:r,; r¡¡

¡?str'3rnt"..,'ãi

r,sed:

I-',:

. .f iur¡rron ?:(ceer!

{:c::rn¡ _

Ptsrt'tn _

3rgrnn'ng

l,t¡?i_

f::tcerns, JeScrrbe
1., t';'?

5.J

nrnure: - niec oar.nt ¡oorc,/ar, ¡i

-:tm €rr:rol

cosl:

o¡rsnls

on _.,1-rcor.i ¡ci;:'on

in'J;r-:g nrnr:

 ,Ê

()lref

ln ulle5 tQ other student3,

rbe what took

place

ro

ñ l,q

ltarf ¡nrj/or procertY damðge:

þ'

¡tter ttme out was complete:

]tuoentlg¡¡gredtheenvllonmentstuJenttr¡nrlllonedtoqul¿t¡cilvllYlnapltvate vofl(soacÊ
prlvate con"ersetlon aboulthe 0enavrol
i('Joent ¡nd ¡tal angaged ln e
towoll( t¡s¡
icudent retulneo

./

lruu"n
:,rrf

-

ralurneo !o lvorl( wrtn the

.ar,nrorrnallv

;taii'r{l

group

¡l ¡ t!am io rllv¡ew

rneet iormatlv

)

;tudent rÈiurned to gen' ec' seltlng

currenl lnteflÊntion s¡rateßlei
dalei

rr ¡ teâm to revrew FIA¡ElP liUe€tlng

time;..l

ordingtothecurrentFBA'lvhatisrhehypothesizedfunctionofthlsbehavior?
:!-e current

_

-*'5

':ãA

be^a.rtof

must také Plðce' see ðoove ro documentl
itcet not ¡ctoresr tnls oânlcular cenavlol lmeÉtln8
-hr3 Cenavtol

tl ñ¡lnlalned bv ac'?s9 to ¡oult åttenl¡on

ihrs tenavlor

1o Deer

atlenllcn

malntalneo bv :sc¡pe trom ¡oct¿l tnreract¡on

r5

-

:r'ì't

benavtor

ll rÍðlntãf ñ€d

-

'ïri

Cå!ltvlol

13

-

-.tis aenavror tr mùrntalnect ov Jutomatlc rernforcernent

r-.n,,

l! m¡lntalneÚ bv access

oV Êscaoe

lni¡rnt¡¡lneo oV

lrom un'prererred laskr of lcrlvltlet
tO

'¡cce!3

(t

9rÈlêrrfd lf e,'f,t'¡Ctlvltjel

þ-

incìdent?
hvpothesrs match the ABC ot this

*.1s,.]Ul'ntefvenllonwi¡Sapofopllataandlnstluc¡lonal/lntervenllonstr¡tEgle'wrll¡tavthes¡me

)

*J" l,ri:"¡Èveloufln(en,entlonrnavnðverg1¡tqrcecthencgatlveoenavlof.i.€team vllllevlewthergSoonseotan.
h€
5€iJriåct€6ieriJsYS¡nd¡lee!lf'gr:!'eY'lwfnQraAr¿Jìll
.¡J.'.i:crvoutnè5rroúel,-"ütiéem¡o.'ð!cniniSri.rcrcen!.,r5cJôt¡"v¡rr

and C¡te ¡ooveI
::qo,JtÈd lolea,se occun:enf ltme

'/h¡t ts'the
¡ow fIìanì/

oeslred replacament benav¡or?
behavtor on  hl5 student,s iEP)
are provrded for t:acning replacement
 TlnUles oi soecrally desrqned instruction

.l f utes and terurcê 0lov cer

/

-r"r23m

¡¡r¡l n€ad to m9ât

!o i:3c!rs ¡odlng mrnules ol

::rent/Gua'rdran contact: Сre: A

?lcortci¡Talaredbv: .
¡

-

5erurce

tln? io:eacn rl'!'r reolacemert 3enâ"lor

-''"' 4lQS Pq

lS'
'

'

"

crntact:

"!¿tnodof

)dmr nrstf ltor il 3nãture

qcatrn3t¡rd to:ne oarentl!'JðfdlÀntfl 'v¡ttln
rr,r:en c¡ov of:re feoorl muit:r
r:å¡ter
C'Jrllrl¿t"'å ÉTlJer rnd id'Jc¿t¡on :lt'/lcEl
lr,,'J c:3 es of feporl lo; Pìr!n¡, SruC¡nt

($
Y
I

 t¡te of oocumenta¡lon

Èi

r()\v,\(:¡.¡y

H-

Suildlng:

-ì6

of tncldenï

leam

Grade:
iims 9f f ¡q¡¿s¡¡,

t4

Lrurðtlon of lncldent:

members rnvolved:

'.Vhat r,vas happening imm
, f ,ght/¡rgument

to the student,s problem
behavior (antecedent):

wrth peer

5tudent rv¡s glven a task (rvhat
krnd of t¡¡k?

:tuden? rvð¡ denred oreferred
åCnvtty- or rtem

-

Studenl

,.v¿¡

-

-iludent

was told to move

-_

tt¡hrt,ttrtrr.'f

dent Report Docurnen
t and Seclusf on Time-Out
Log

S,.,0 ent:
l¡te

"

.-

Strrdent

wa, e¡oeçted to transtïon

-

to ¡no!her loc¡üon

.iIr ñr\ c(¿trtL

5tudent rv¡s gtven one_on.one
attentton tde¡cribe:

.t

Other

_

ïeacher wa¡ ¡ttendl
ng t0 other5
5tudent rvas promptec,
to usE tpectflc replacement
behðvtor lwhlch one

a¡ked !o rvalt

r

,í'

Príor to restraint or seclusion, please
descrl be the de-escalation
strategies that were attempted
by staff:
ioom cleôr lr€move audlence)
Set ¿ trmer
_
Olrect to cool down a
reð ...
Olfered choices
ttf,rhen)

æseil¡mirr
rlrompttng

u5e

,gno¡tng

I / l/j./
i U'r/_¿:í",-

"n-i-¡1t

for cool down

(not provrding åttennon
for escalated beh¡vrorl

of replacement be havlor

_

Fir¡t/then

Student
non-oggressive beh avior prior
to restfa¡nt or seclusion:
ilI
5tudent oqgressive be havior prior
to restraint or seclusion:
r.l

F

i,/1,

...,..-

Student ogg¡essive behavior
duríne restraínt or seclusion:
---

ïime

out:

I

I

¡, ,

i..,

.

llme: :r ¡' 1, ênClngt,me:
rnavatl¿ble, need àdmtnts
rr¡tor approval (document
tlme/apo roval)
Physical

3egrnnrng

restrainti

_ ito Jrc,

,,/*,,¿r

'ai

'

lf duratlon e¡rceeds 50
mlnutes _ need parent
aoproval, rf parent l¡

t0tþ-lu:t4
rn,

rân,.,

posrrion

,3eginning

!valuat¡on, rf ohysrcal relt¡arnÌ
r,¿¿j used:

-.-

llo Ccncerns

t-êam control posrtron

t,mer

-

l0 : l{ -lo" tg
,/ ,,rîoo,, ro,,,,o"

ãndjng.mei

tcncerns, descn oe;

: jr:atrr?t

_-

 :¿5cttb€ othef

rrrlurrer to

pfooertv oDmðl€i
cther ¡tudenls' rtsrf 'Ûnd/or

took place
0escr¡be whðt

3fter time out was complete:

t

5fudentrertcrertthcenvlronrnen

rn a

the oehavror
p.v¡t€ conversatron abgur

ituoÊnt and ¡ta' en'aged
-Stu'JentlransltlonedtoouletðctlvrtYlneprlv¡¡teworhrpðce

J ;r.,oent returnro to wor[ rasK

o

'-irudenreturnedloworkwrthlh€group*Studen!retufneÚtogen'ed'lettlng

-¡)

it¡,if

r¡et lnfcrrarlv

5 taii

thÊr:

AccordinE

rvrrl

33

lnten'Êntlon stfalegles
t :eam !3 revrÈw culrent

me:t formallìl

å5 e

teim

t'

úate/time
revrrw FBA/BlP lNleetlng

d function of this behavior?
is the hvpothesize
rvhat
FBA'
current
to lhe

to documentl
tak¡ place' see aoove
beh¡vior (meeting musl
paßlcular
thls
no¡ addres¡
current t3A dcel
by access to peer åttentlon
f hii b€havlor ts matnt¡tned
¡tlenllon
ðdult
to
i5 malnttlned bV ¡cces¡

e
¿e"h
t t" -hi 5 Ueþðvlor

lhls

lnterâctlon
by ercrpe irom soctal
behavlor r¡ rn¡lntatncd

íhrt

bv eScape from un'prelerred
oen¡vror lr mðlnt¡lned

thit

bÈnåvlor

li

t¡rk¡ ol actlvlllet

prelerred ltemr/actlvrtle¡
m¡lntðlned by accesr to

rhrs behðvrol t¡ matntatned

by outomatrc retnlorcement

match the
Does this hvpothesis

ABC of this incident?

t

Wrll stav the same
nterven¡lon strÐtegle3
and lnltructlonaui
ðppfopllate
wð3
plan'
'/e5, our lnterventlon
wtll revtew the responle
behavlor' The leam
egetive
n
the
maY hðve rernforced
ew the FBA wrll be
'/e5, howevðf oul lnterventlon
and a meettng to revt
be collected for 5 dav¡
lvlll
dtta
ABC
thts lncident'
doet not reem to match
¡l o, lhe hvpothest¡
above)
doçument trme and d¡te
scnedul ed tpleate

desired replacement behavior?
',Vhat is the
nt behaviol on this student's
ded for teaching rePlaceme
are
Provl
instruction
sP eciallY deslBne d
How manY minutes of

lE'P

:,linutes and rervlce Provrder

lhi¡ replacement behavior
oi seruic¡ tlme to teach
.,nu,J,
eddlng
disculs
lo
:he telm wrll need to meet
rLozl

ca¡s¡¡/Guardian Cont act:
)ecort

,'."' ß " 'J5

oa

-

Àdmlnlttralor 5: gnaturei

complelEd bVl

¡

tJletnod of contact:

¡/fitten copv of the reoort

wtlhin ¡hree dav¡ ol the lncrdent'
m¡rxed ro the parent/8u¿rdi¡n(¡l

Educatton
Cumul¡tive tolder and
j¿ntl copte¡ ol report toi Perenl' 5tudanr

Servrces Cantêl

æ

 :.lte or 0ocumentailon:

q

/v.

ls

¡()\Vr\ (:l'tY
s lltlrt lrl\lll¡.r

,Ø

lncident Report Document and Secluslon Tlme-Out

)

rldlng

ud en t

r¡r:

cr

rncroenr; q

-:¡m rnembers

lVlS .-

õ

:' r? gf Inctdent:

l2',

ço - llas

r¡de:

--Jrutron

¡i tncldenr: t{ 5

rnvolved:

,'/hat'.vas naopenrng ¡mmediatelY prior to the student's proolem behavior (antecedent):

J

¡tttrgurnent wrrn

oerr

lruJent wðr grven ¡ ¡arh lwñåt krnd oi t¡:k?

::'JL:inl w¡5 oenred orererred ¡ct¡vtty- cr ,(em

_

(udent r.r3t ,¡sl(e6

-

'tuúent

.,vÐr

to,¡.,åtr _

:turjent was eroécled !o trrnstüon

nʡ

¡l1a ñdtñt

lô

;fu,tent w¿s otomoteo to use !pectilc reolðcement len¡vtor l,.vnrcn onel

(otó to fro./e lo Snotner toc¡tron

::'J,,ient 'Jri¡! qtven cre-on.ore tt¡enuon t':ercflðe:
:

-i!år:

,)'ior to reslrülnt or secluslon,
rrJoflr

\-

)

:¿l
_

i

?3r t¡Èrnove

rn'r9 l1,

.:i?í¡ct:rl

iìudent

please descrtbe the ce-escalatton strateBtes that\^/ere attempted
by staff:.

¡uorencEl

:!':€nl

i*!

trmel

)rrectto cool oown

aret

¡t:entron tot ¿scalaieo
i.orì.3 tnot orovrorng
-

---

Jte or r¡5'ôcament

a

cgnavtor

behðvrof

)iiìer:

,Jferedcnorcg¡ ior c¡ol .:own

I

-;ir¡rllhen

non-aqgresírve oehav¡or pnor to restratnt or seclusron;

+t^r?
riuüent

oOqresSive beha'¡ror

Jfudent oqgresstve

oflcr to restrAtnt of

beha,¿ior during

seclUSrOn

restr¡int or seclusion:

-'mg out;

r

3agtnnrng lt^"t-l*!l
:-drng ¡trel l.t Zl
'¡./Àr'åble. r?30 !ornrn 5ir¡tct ¡oofoval looc,-lnen! :rnre/aoprov¡rl

'?h','stcal

restrainl:

4'u,

¿t

-'io
\ :'/.!,uð¡,on, í .-"'tt ctl t?5Ìi'alrìt i/ã!

-'

if cur¡t¡on r:(ceeot

dren'¡cont¡:l

pc¡rtrrn

iJ nrrurer -

n€ed oar.nt åoorovar, ,i

eo¡rron

3rgrnnrng¡rr¡e:-'rrmf¡..:!rol
/!ll
:nlir.:lrrrn!;
rrsÈd

/ .'."rj:n::rns

J:scrrbe:

-r:ircern:,

o¡renr r¡

l?ll.
-,¡r:!Forrp,ri,:,cn

 e r:(nef rrrlulre5 to otñeÍ itudent!'

tbe wnat took

place

tl¡rf

¡Íter ttme out was complete:

,*,,.,o.n, resrored rhe envrronment

J

'lcudent rêturneo !o rvorÍ

a pilvate work soace
trÐnsrt¡oned lo quret 3cllvrtv ln

Jj

"u'*nt
j(!Íent
j?r.,jênr ¡nd

tasK

,:tuúenttêturneo!o¡vorlrvrtntl"egroup
- l'.¡rf
;

rner rnicrratlY '!s

tðli

'¡/rll

N/A

ðnd/or proccrw damage;

gtarf
rn ð pnvale con'/erlatlon
engaged ln
starf engaBed

¡bout the oelavlor

itudenrletulnedtoEen'ed'se(tlng

5!ra!êlle3
¡ team !a let'lèw cuflent ln!êfl€lltron

rne¡t iormatlv ¡l

å

datei
team to :evtew F3'f/8lP ' fuleetlng

lime:

¡

ordinqtothecurrentFBA'whatrs(hehvpothesi¿edfunctionofthisbehavior?
musr take place' see aoove to ctocumentl
lnl5 Þ¿rtlculôr cenavlgl lmeetlng
e curtent É3A,Jcsr no( sddlest
-þtr 'oenavtof 13 rn¡lntalnrlo bv acce55 lo peel alle n(lc n
-rr5 þ6n¡.¿¡6¡ l¡ ni¿rn!ðtneo bv ðcc¿r9 !o ¡ldult ¿ttenllon

:a

soct¡l lnrelacllon
-'115 Eenävlor rr rnalntalned by ¿scrpe lrom

-

-r.1,1 :gnavror

t¡5k! ol'Scllti ltlel
ti rr¿lntalned by escace irom un'prererred
reo
arntðlneo oV ùCcesg lO Orelaf

lta'îl'¡Ctl'Jltìel

-

--'ìrS Ceîavlof ri

-

-11,s !en?vrol tt mùrnt¡lnect ov Jutomð(lc r¡tnforcemenl

lt!

-Jes rhis httpotness match the ABC of th¡s inci{ent?

/

Ês. ,r'.Jr nrervenÍton wås

5trategler w¡il slav the
apgroorlat' ðnd rngtructlonal/lnten'enllon

sam€

*,' 7'\c,.vÈverÓuf'ntenientlonñsVnirvefe ñlorceclthenelallveoenav¡or.iheteåmwtllrev¡ew!heleSoonseot¿n,
1r .?v,¡!.,"
â
ÀÈc J¡t¡ lvlil !e :fl.¿(leo ler 5 d¡vs Jrá -eet,ng
iÉem ¡o...ðtcn tnlt lrìciûêni,

\

)
tnq

tlA .¡rll h€

¡\), ,'îe llYLUtn€5 5 oce¡ tlot
¿nd Cale ¡oovel
I olea5e:JocJn:9n( tl'rre

:rqorleo

1e

benavior?
'jh.¡t ts the ceslred reolacement

)
behavlor on tnrs student'5 tEP
replacement
t:aching
ior
provrded
tion are
-¡ow rrìanv rrrnules oi soectatly destqned instruc
,: ru¡as and 5er',lca olov cer

.!e1e¡m.rrrrlr€ed orxee!!oll'cJsrrodrngm.nutetoisen¡.ce!lti.e(o:e3cntþ.¡reolacerner 3en¿',lol

: 1¡E¡l/Guardran Contact: c¡te:

II

,v

',,"' ?-"9o

..,¿lFod of

lrJm'nrStl'ttOf

2ecort :tr¡t.Èted b"i

I

¡frrleñ

C]OV Ol

l¡^l

!¡ntact:
5l

gn¡ture

oafent/l'J¿fdl¿ntil 'trtnln
lha l,oofl mutt 3e oc3!m¡fhed to i¡e
"h

cccte¡ of '?rort Ìoi

P

lrlnt'

:l'Jdent C"rñ'¡l¿l'

Je

ft

Jer lnd !'Juc¿l'on

f'€

V

 ¡

-ì*e oi oocumenraron:

I ln / S-

l()\V,\ (:l'¡Y

1o

v lh¡tt lìrrt{t¡.r

lncident Report Document and Seclusion Tlme.Out Log

q

l¡te cr lnctoenti

-:¡m

'"r:oftncrdenv

:luueilt

oeer

_

:

:t'JJent,,vår gtven à tark lwnðt k¡nd of ta¡k?

ol

wå¡ oenred oreterr:d ¡cirvrlv

_

_.cuúent'lr!i¡sleútowðlr

_

15 *^

--Jrrrroncitr.cidenr:

naopenlng tmmediatelY prior to the student's proolem behavior (antecedent):

. girr¡argurnent tvtn

_

13".ÇO'. I :35

memoers ¡n,¿elved:

;/hat wås

V

6racle:

õurlding

Student

,!em

jtu'Jent w¡¡ e,(pect ed to trrnsruon

_

itu':ent\ ¡å¡oromo!€otouse¡9ec¡ilcreotðcementcen¡vlof

Í:lcnpr,-ver :ttÉnatrns to
lwnrcnone¡

ruúen(.,va¡ tord to r¡ove ro ¡notnef toc3gon

:Ì,rjènt'.vðr

q¡ven one-on.oFe ¡tîen(ron

rÕetcnÞ€i .-

.

.,

.. t'.

o

,r.ior te restr¡rnt or secluston, please deScnbe the de-escalatron itrategtes that were artempted by staif:.

\-

)

:rJGrl r'Êilr rr¿move

:+t'rn'rt
li:ÍTrc!:f'¡.

irt,
J5è

l:t a trmef

¡uutencel

:nenl

--¿

oÌ r¡riac€rnent

!o cool oown

-a:reçt

Ðret

,Jl.erad cnorce¡ ior cool .Jown

inonng (not orovrornE ¡rientron tor rscalâreo Þehðvrorl

-;:rr!/then

cenavrot .)i;ìer:

::t'1dent non-oaqress,ve behavror pnor to restratnt or seclusron:
I

;t'Jüent oqgrest¡ve beha,¡ror Qflqf to restraint or

seclusron:

'Jtudent aqgresstve beha,¡iof during restr:¡nt or seclusion,:

f,o,
î'me oul:

,,^"tli l2

¿^dirI trr¡e:   : 3l¿.â./àrr¿ê €,.?eo3dm n5ir¡!cl¡oorovalfoocl,ment::Í¡/ðoprovàlli
3egtnnrrg

:þ'T5icalrestraint

¿

c

-_ ,îÍ _

' 'f cur¡r;on excreor 50 ¡rnures -

!h..Cren's Contrrl

Pc:rt'¡n __ -rtm l¡r¡rcl

3+grnn,ng

(þ
)

ivi,uatrÇn, ;;ryl ctl r?6ti'¡tnt',./ar

rr!ÊC

¿

â

C:n:irni _

l¡tt€:-

ti:rrern¡, Jascnb¿
.t- ll,':.2

need s¿r?nt ¡ooro./¡t, ,i

pos¡:

inlin{

on _

rlm?:

p.r?nt

,s

-,¡-çpol.! pcsr:,cn

 rt¡rf ¡nd/or prooerw Camage:
:E t:rrer rnturrei to ¡th€r rtudenls'

'rbe

.';l

-

wnat took place

Lîo"n,

rerrored rhe

;¿

liCuOent relur¡ìeo

rO

¡iter ttme out

,G

jÞ'

was complete:

, fl
envrronment -l--

worl(

NIA

prlvãte worl( soace
sturent lr¡nsrtloned to qur¿t ¡ctlvrtv ln ¡

¡bout lhe oehavlof
gfrvate Conirersatlon
conversatton 3bc
In ¡ prlvate
:rr,.r¡nr and
rñr.r Starf
*aí engaged
anzased ln
i('J'Jent

(¡t5¡(

)

- jtudentrQrurned!olvorr,.,rtntþegroup
- .:¡rf

rnetrniormatlv

¡t ¡ t3am Îo revlew

it¡ti',vrrr rïeàt ioimallv ls

å team

lntêruentlon rlra(e!¡let
curlent
-!tudenlretulnecttogen'Êd'settlng

to revrew i3ùðlP tÑleetlng

date/timel-)

lr:

ordingtoth,ecurrentFBA,lvhat stnehYpothesizedfunctionofthisbehavior?
ec'Jlr¡nti3ÀJoe'not3dofe!5(nlScaftlcu¡ðlQenavtof(meetlntmusltakêplðce,leeaoovetodocumentl
-krt ber¡vlor r! m¡lntalneu bv access to 'Jeel åt!¿ntlcn

-h's

attentlon
ceñar¡ot rt m¡tnf Ðlñe6 ÞV aclsst to ¡óult

'

!anavlor

15

t^tÃ.t.lt^^
-^-,^l
ír¡ln(¡lneo bv åsc¡pe trom ¡oc:al lnteraçtlon

-:htt :tì!5 :snðvlor ll mðlntalned ÞY erca0e irom un'prererred
*
-

ûes

n

p

lle'nt/¡Ctlvlçle5

'ïr5

tO prêfeffêC
C€^qVlor l5 mArn(alneO oV ¡CCel5

-il,s

rsrníorcement
aen¡vrol ! mðrntalneo Þv ¡utomðtlc
f

thls hvpotnesrs match the
,

lasks ol'Sctlvltle!

ABC of this inciQent?

stav tne 5¿me
and lntlrucllonal/lllteilentlon itfategle! "vrll
+5,,:ur ,n(erventlon wåi aporoprlåte
ilere¿mwlll rev¡ewtheresponseotan.

)

1,,.7,1c,.v€vefoullnteflentlonmevnaver!lnlorcectheneg¡tlvecenavlol'
..\).,.ièllY0u!l1e515rJr]È!lro!i€emÌo,]:¡!cn¡nls
¿nd drt¿ ¡oovel
I olease oocument ttme

he
lnc íeni,,\gcJJ¡J..v.ll ïe:J ..ctedicrj'j3vs]Fl 3-eet.ng!c.ev.€,¡,tnetlAwrll
I

:rrouieo

.'/h,lt t5 the oeglred reolacement benavìor?
student'5 iEP)
provtded íor t:acning replacement behsvlor on thrs
.{ow frìanv r.rrnures oi specrallv desrgned instruction are
.'l

rrites and

-.e

5elvlce

clat ael

l?3m,,.¡:,1

lo i!tÊl'ì:hls reolacerenl 3enàvlor
f:?:d to n€Ê!:o ll:cuss aodlng m.nu:e5 oi ¡en¡.ce l:fì9

,t
lrrent/Guardran ccntact: Сre:

:;port:õrt.itâd

qlv

'',n"t

-@

ccnt¡ct:
"!¿rnodof
¡dmrntstf ìtor Slsnature

bv:

¡

lne o¡rentlt'råldlanlSl ¡rtnln
rrrítån t-:oy ct 1l'e letorr mutt:e ocslrn¡rked !o

avf

lnd:'Jvc¿tlon:er'/11:¿tf,êr'ter
:¿^lcaorerof leooltlo:tlr?nl.'t!áÈn!r!rn'¡l¿t¡¿t-îolzl

i@

>

 J,1te ol Document¡tton:

¡()\\'r\ (:t'¡Y

Ð

o

'{ ll¡Ntt

tÍ\l[ta.t.

lncldent Report Document and
Secluslon Tlm e-out Lo

Studen t:

uildl

I

: rte oi tncldenr:

leam members
',Vhat

iime of lncrdenc

',vas happening immediately prior to t he student, 5 pro

itudent

peer

K

I

-$:*cenß',rð5

0

havior (antecedent):

r,, denr rva¡ srven a task (rvhat

lvðr denred preierred .ctrvrtv
or

Student w¡s
wcr.t¡(eq
¡sled t0 rvatt
_
_
,=.*""r,rr

_

lurôtlon of tncrdent:

involved:

r,ght/argumenr rvrrh

-

6rade:

rrem

krnd of t¡sk?

5tudent lvas exoected to

úlLlOJ,t,h

transr¡ron

-

"*

,,'e¡cher lva¡ artenotng. to oth?rs

:tudent,.vð5 p¡ompted to use rpecttlc
reptacement beh¡vror (which
one?

Ìotcl ro move to anotner tocrtron

5tudent rv¡r gtven one-on-one ðttentton
¡rje¡crrbe:

Dtheri
Pri or to restraint or seclusiorì' please
describe the de'escaration strateBies
that were attempted by staff:
ioom clear tremove audlcncel
set r ttmer
orrect to cool down

area

O-:ertim*sfit.üen)-

prornptrng use ol replaqement

f

'gnonnt Inot provtdlng attenüon for escalated
behavrorf

behavlor

Offered cholce¡ for cool down

_

Firrvthen

Ot

student
non'oqgressive behavior prior to
restraint or secrusion:

(5t de

eh

r

to restraint or seclusion:

Student oggressive behavíor durinq restraint
or secrusron:

CPT rn

ö
iime

out:

3egrnnrngt,-e,

iì5'?

¿n¿tng¡n"&!]-7

:avarlable, neeõ ådmtnrstrator approval
ldocum ent tlme/aporoval);

Physicalrestraint

ilo

å

?l

a

lton,

'i

¡l'v¡tc¿l re5lrarnt,,vås used

' 'f Curatlon

rihrldran'¡ c0ntrcr

:Yðiu

-

r¡oConcern!

erceeds 50 mlnutes _ need par€nt
aoproval, if parent

pos¡tron

rs

-* ieam contror pos¡tro, 'r( r,¿n¡port posrt,cn
,3egrnnrng ,,.., I ,S.5
îndrng timer i ,j j

_,JcncernS,deScftÞe:
i'd:ature

 ,:

: Scrl b

e

Qfh

er rr-rlulrei lo cthef rtudÈnls'

Descrtbe what

.

ri¡ff tnd/of prooef ty comage

complete:
took place sfter time out was

iludentreltofeotheenvrronm'en

I

.liludent¡ndgtaffengagedlnaprlvðteconver'etlonabouttheoehavtor
-studenttransrlonedtoouretactlvrtylnaprlv¡teworkSpace
K itudentrelurned lo "!orl taSl(
lettlng'
f
. .--,. ...-.L .-à "^rrô
stuclent l¿tutnerJ to gen' ed'
d siudent'eturned !o wor\ wrth tne group
-

+-

5t¡if
'

m¡t rricrr'natlv 3t ¡ :êam

5lail

rvrrl

tl

û

revr¿w cuf rent lntervenllon Strategle!

Ê34/alP lr\teellng úate/time
nee¡ iormall,, a3 a ie3m !? rev åw

r)thÊr:

åccordingtothecufrentFBA,whatisthehvpothes¡¿edfuncionofthisbehavior?

x-

:he currrnt t3A dcêt not 'ddretr

thrs pantcular behavtor

(meltinl

¡rtention
'hii.uehavior ll m¡lnt!rned bv access to adult

ihlS

bah¿vlor r¡ m¡tntalned EV e5c¡pe

.Ì.rìi9

oehavror

*

to documentl
must take place' see aoove

tg peer altentlon
fhir beh¡vror t¡ marntained by acce:r

irom ¡octal tnleractlon
-

tasks ol ðctlvltlel
rnðrnt¡rned bv Êsc¡pe irom un.preferred

to prefetred rtems/¡cltvttte¡
Thls ben¡vtor tr fn¡lntalned bv accelt

rhts

behavlor

15

malnt¡lned

bV ot¡tomatrc

Does this hypothesis match the

retnforçement

ABC of this incident?

stfategres wrll staY the sãme
and inftructional/interventlon
'/eJ, Ouf lnterventlon was approprlate

the resPonre Plan'

t

./eS,howevelourlntefven¡tonm¡vhavcretnforcedtheneBatlvebehavlor.fhete¡mwtllrevtew

revlew the tBA wrll be
for 5 davs a nd a meettng to
ABC dùta lvrll ba collected
inctdent'
thr¡
match
to
seem
not
¡lo, lhe hvpot hect¡ does
(Plea:e oocu ment tlme and date abovel

rcneduted

replacemenl behavior?
',Vhat is the desired
student's IEP'
replacement behavior on this
teaching
for
provided
are
instruction
desi
Hor¡ manY minutes of spe cially
:Jlinutes and seNlce provtder
addlng mtnutes
fhg t?am wrll need to rneet to dìscu¡r

lr-

2¡rent/Guardian Cont

behavtor
tlme to telch thi3 replâcement

i¡ethod of contact:
Àdminl!trator 5r gnature:

"¡Fott

cOrpleted bV:
rå ¡rntlen

c0PY

three dav¡ of the incldent'
ro the parênt/Suardian(¡l wrlhln

tolder ¿nd E'duc¡tlon S¡rvrce¡ Cenler
'¿nd copler of report toi P¡r€nt' Student Cumul¿tlve

@

 -ì,rte

ol Document¿tlon:
i
_-li
: r !
,i

t()\v,\ (:t'lY

Ð

c

ent Repo

Studen

:¡re

01

Iuã ã

rfl

rnqdenr

-l

i

r

- !i í

{ Í.r¡it ttt\tßt¡.1'

Document and Seclusion

I

Suildln

;::

iime of lnctdent:

'luratron of lncrdent:

2b

i¡'l\v'l

m ernbers rnvolved:

',Vhat lvas happening immediately prior to the stúdent's problem
behavior (antecedent):

,'

:,gnt/ðrEufnentwrthpeef
:tudent lvôt

_ltudenrrvãsgrvenatask(whorkrndoftask?

denred preierred ðctlvttv or

lo',vðtt _

rtem

ltudent

_

:tudent war told to move to ¡nother loc¡tlon

_

-l

transroon

_

îeacher wðr attendrng to others

itudsnt ls¡s -prompteo to use specrtic feplacemlnt behav¡or (which one?

_
-

wai aiked

Student wðs erp€cred to

.

_

I

5tudent 'rôr gtven one-on-one ¡ttentton ttjescrrbel
i

r)th€f

Prior to restraint or seclusion, please describe the de-escalation strategies that were attempted
by staff:
100m clear llemove

ü-

!et

)/

limi¡s lrf,

audiencel

thenl

Set a

ttmer

oif ect to cool down

¡re¡

offered cholces for cool down

'gnorrng Inot provrding attentton fo¡ escalated behavror 

_

Õ

First/then

,:romptrng ure of replacement behavror

Student non-oggressive behavior prior to restraint or seclusion:

5tu denl aggressive behavior prior to r estraint or seclu ston:

I

.,''1

Sludent oggressive behavior durinq restraint or seclusion

Time

out:

3eglnn¡ng lrm

{O,Oq

Éodingrime:

J&

'

lf durat¡on exceeds 50 minutes

:-avaliaole, neeo ¡dmrnr!trator approval (document trme/aporovai):

Physical

i¡o

restralnt:

rlLa:'cn' rf chy¡;cal r€!trôrñt

6',

/!t
-

,,var usect:

conrrol

-rlhrljren's

po3rtron

.3egrnning

o^",k\)(t
6

ccnc¡rns, de¡cribe

{-rt.ccncerns
-

j-eam

l;rature:

-

neeC p¿rent aoproval, rf parent

control posrtion
Endins ¡,me:

Xrrðirporr

lþ,N

rs

PoiÌtron

 r¡lufret to cther ltudents, rtad õnd/of prooertv d¡mðgEi
.--¿scnÞe (fther

Oescrrbe what

t;(

took place ¡fter time out was complete:
StudenttransrtionedtoouletactlvltYlnaprlvütewofkspace

!Èudenttsstoredtheanvtronment

itudent

feturned to won

tasx

SiuCJent'elUrned !o,.vorq wrth tne

:tJf f

mrt:nfcrrnatly

¡¡

:talf engaged ln ¡ prlvate conveflatlon about the oehavtor

gtuoent ¡nd

+
group

@

returneo tO gen, ed. ls$lng

r :¿am tJ revlèlv cullent lnlen Èntlon stfalegleg

-studeñt

t) the

r

Åccording

'/ '

to the current FBA, lvhat is the hVpothesi¿ed funcrion of this behavior?

'nrr[ehavlor l¡ m¡rnt3rned bv accerl to adult

ottention

rhig behavlor i¡ matnta¡ned by access to peer ättentlon

Íhl¡

behavror

tt malntalned

bV e:c¿pe

from ¡oct¿l lnterðction

ïhtr

behav¡ot

lt rnatnttrned

bV eSC¡pe

irom un.preferred tack¡ or actlvillet

Thl¡

ben¡vror

ti malntalned by accÉts ro preferred ttems/¡ctvrtter

rhtS beh¡vtor tf m¡tnl¡lned bv ¡utomat¡c retnforcement

Ðoes this hypothesis match the ABC of this incident?

O

'/Èr, our rnierventton was appropnate ¡nd ingtructlonel/interventlon stlategles wrll stay the same

@

,/er, howevet our rnterventton may have rernforced rhe negatlve behav¡or, lhe te¡m wlll revtew the reiponse plan'

u'

llo,thehvpothe¡rsdoesnotse€mtomatchthi¡incident. ABCd¡tarvrll becollectedfor5days.ni.t".ttngtoreview¡heFBAwrll

be

scneduled (pleðre 6ocument tlme and date abovel

'l/hat

is the desired replacement behavior?

on this student's
How many minures of specially designed instruction are provided for teaching replacement behavior

IEP?

'JtnuteS and servlce Provtder
ãcement behavlor

Ths te¡m lvtll need to meet tg discust addi ng mrn

P¡rent/Guardian Contact:
?

¿port cornpleted bV:

Date:

'i:.1lì
I Tlme:,Ë

l,lethod of contact:

ldmlnrstrðtcr srgnðture;
å .vr¡¡ten copy of the report murt b€ ooilm¡rked ¡o the parent/Suardian(!l

,,vrlhtn lhree dav¡ of ¡he tnctdent'

:¿nd coptet of report to: P¡rent,student cuñul¡tivc Foider ¡nd Educ¡¡ron Servrces Center

æ

@

 -lJie ot Documentültonl
t:'
¡,
rì

l()\\"\ (:l'lY
w*f
:H

I

{ llr rlrt ttt\t t{t.ti

o

ent Report

5rudenr:

3urlding:

: I të ot lrl crdenr

:',:1r of Incrdentl

leam members

c

lon Tlme-Out Log
6rade
lurat

on of lnctdent:

f '\_

fr\-,'-'i'\,

rnvolved:

'.r/hat tr¿as h aooening immediately prior
to the srudent's problem behavior (antecedent):
¿ht/at 3umena

wr(h

reer

-É-'
_

lludent',vðr

_

itudent

,,vðr Jsked

!tudent

w¿r told to rnove ¡o

Jtuden('rat

-

_

itudant wðs gtven ¡ t¡lk {rvhðl krnd
ol

oenred oreierred ¿Cl¡vrty Or,tEm

to.,vart

t¡¡kI

5trrdent ,.vas e.\oected to rransrrron

ittcent w¿i -promoreo to u5e roec¡Îic reptacement

_

I

i'¿åcher rvðs

¡lterdrng lo olhers

-

behavrof lwnrch one?

¡nother loc¡tron

grven one-on-one

¡tlent¡on tdêsc¡rbel

r)therl
-

¿

.1,,..i-,ì v1 r":--i1"' t'*
,o ,.;;,)u,"Iil;¡.ì¡ sion, pl ease
descrrbe ¡he de-escalailon srrategies
that r,vere attåmpted by staff:
loom clesr rremove audrencer
iet a trner
Ðirect to coor

)rior

t

down area

j¿t

hrnrts (rf,.rhenl

jfornptrnt

'inoflng Inot provrding ðttent¡on for ¡¡cal¡ted
behåvrorl

use of replaçement

hehavtor

c

Offered chorce, for cool dorvn

_

Fir¡ll¡hen

O

Student non-aqgresslve behavior prior to restraint
or seclusion:
i

5

- *-,\..

tudent cqg retsve behavior orior to restraint
or seclusion:

i I ude n t

og

g ressiiíiehavror duri nq resü¡t

:''¡e out:
' 3v"lt,

a

;

I

e,'

¡

3eg,-r

r¡ r..u

gc ¡¡:T'nrst-t

:!','s'c¡l r:slraint:

lcf

;

c

*

,

oro¡/A I i

K

t
J

'.'

'

n

t or g eclus ron:

,.",",

:t,.mert,,.

t:.

,,-a,
/ Jaell'l¡il

' ' j :'..:r¡t.¡n e\cEec5 :0,n¡r.¡:es

Þ-

-

@

.-':-'::¡^ri

r?ed ol¡311 ,ootc,tal,,,

K
,:?ra,.lÌrrr?j

¡'l rli'.?1, ; :,-'.,i.;¡l 'i!:"1 -:;tis,t:i,

_

;i::..

.:

'¡-a^^rra^..^^

to:Llrl :;:'3t..ni:le4t

:,

.ì".:

t¡r:nl

s

 @

@

¡J;¡LÊ:c::JocÈJ¡:¡å'ii:Ê''
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 f

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F;

ate of Oocumentatron:

10!v,\ (:t'¡v
g llrhrt

lrtñtttajf

lncldent Report Document and Secluslon Time.Out Log

)
5ludent

Suilding:

l¡te of rn'cient:

q' k'

ii,'ne of lncrdenr:

I

r

6rade

lÐ. 2

2{ *,¡,-

Duritlon of lncldcnc

Team members involved:
',Vhat was happening immedlately prior to the studenf s problem behavior (antecedent):

_

:tUd

i

-

-

.,-l

^
-

e

jtudeñt wði grven ¡ task f what kind of ra¡kl

_

wrtn peef

nt rvås oenred oreferred ¡c¡lvity o r lte

tudent wai

walt

¿sKed to

m

.

_

itude nt rvas expêcre d to trans

 Îion

_ feacher was

Srudent wðr prompred to use specrflc reDlacemen( behavior ¡wnich

---

ane ndtng lo

one?

c

theß

J

!curjent wa¡ rold ,o .ou, to another locauon
;tuctènt wås gtven one-on-one ¡ttenlton

tdescrrbel__

I

!l.er:

Prior to restratnt or seclusion, please describe the de-escalation strategies rhat were attempted by staff:.

*.l...-.

J

.ìoom Ele¡f (iemOvr

iet

_

l¡mrts llf,

.lrtmplrng

jludent

Auotencel

thenl

iet

a

tlmer

J¡rectto cool down area

_

rgnorrng (not providing a¡rentron for escalðted
behðvlorl

use of reolacemenr

behavtor

OfferedChorce¡ for cool down

_

tìrst/then

ùther:

ÔY

.çec

non-oggressiye behavior prior to restra int or seclusion;

3tudent

behavigr g-f.!g¡

SASnn y\^ocl q.,hen coLtd

d

seclusion:

Student aqgressive behavror duríne restraínt or seclusion:

lÎmeout:

3egrnnrng,,re:ld*Â-9 lrd¡ngrrme: lö:.¿/tl

n exceeds

minutes

- ncid oerent aoprov¿ , ¡f oarent

¡¡

¡¡¡varlable,n¡ed¡dmrnistratoraoproval{documentttme/approval  

Physical

O
)

restraint:

_

¡ro

]L trs

_

Segrnnrng

Svalua¡ron, if chysrc¡l restraint

'n., ur.dt

{

)lo

(

Children'¡ Control Positlon

Concern!

¡t

"t

lÔi

Cañcernr, descrrbe
'rignarurp:

fa¡m Control Posrtion

d

ZO

t'.2(-r.

:nd¡ng rrmei I

.

,runrro^

Posrttcn

)

 proFerry damaqe
tbe other lnlurles lo other sludenti, 5tarf ¡nd/or

:rrbe what took place ¡fter time ouì
rEs¡Ored the

- 5tudcn¡
_

Snvtronment

icuoent

return€o to worr

jtudeñt

ferutned !o wof

-

*tt complete:
and ¡tatf engaged rn a pnva!e conversatlon about the behavtor

task
l(

ü

Student tranlrtloned to qulet ðstlvlty ln A prlvale work space

Þ

-{-itudent

wrth the

group

Student fetuf ned ro gen, ed. settrng

ff met iniormallv ô3 ¡ team to revlÊw cullent
- lnterventlon stratetlet
- i¡¡
; taff wlil meer formatlv a5 a l3am to revlew tðA/a P trvleetlnS datei lime:---}
tr:

:ording to ille current
:ne curfent lðA

_
.

FBA,

what is the hypothesized function of this behavior?

place, see aoove
.Joes not adoress thls pafttcular oehavlor (meetlng must take

attentton

lhr¡

benavlor r: marntalned by acce's to adull

îhis

benavror ts matntatned by escape from social interaction

/ :'',,, benavror r¡ matnt¡lned
,è-

This behavror

bv e'cape from un'preierleo tasks orEct¡vltle!

rs

to documentl

malntatneçj by access to Þeef ôttentron

Q-\,,,'1\;

èo.^rYt {a=t.*.

;htÉ Qenavlor ri marntalned þv access to oreferred ltem¡/acttvltle¡

-

o

7l'ìts cehavrol rÍ malniðlned ov ¡trtomatlc retnforcement

-)es rhis hypothests match the ABC of this incident?
strategle! wrll stav the same
¿s, oul ¡,.rtÊrv?ngon wàs aopropnatg and rn5tructronaUinterventlon

X

)

., es,no,.!ever our rnterventton may have rernlorced rhe negattve benavtor. fhe team'.vtll revtew the response olan'

_

:'¡o,tnenvrjotnetririùÊsnotse€mtomatchthrs¡nc,¡dent. Asc,J¡tðwtllbecallectectlor5d¡vsandarteetlngto'evrewlheFBAwlll

ñ'"o

be

tolease oocument tlme and ctate ðoove)

Vhat is the desired replacement behavior?

lãcement behavior on thls student's IEP?

low rnanV minutes of specially designed instruction are
.'lrnutêS

ãnd rervlce Orovtder
îhE team rvrìl need to meet to

r:rent/G uardian Contact:
¡:oort

como¡eted

cate

ctscuss aoding mtnutes

of servrce tlme to teach this renlacement behavlor

l.5 ;'-e: t I ;0Þ

\¡êthod of contact
ldmrnr¡trator sign

p¡rent/Nuðrdiânl
å 'Jntt?n cooy of thr leoor! írusl 5e óostmarked to the
c¿nte¡
l¿nd ccores of report !o; P¡frnt, Sludent cumula¡tve Foldel ¡nd educ¡tron S¿rvrces

t
-)

 late oi oocumentatron:

t

IOW¿\

ì-18 -ts

(ll'lY

lncident R eport Oocument and Secluslon Time-Out Log

)
Student

l¡te

of lnclqent:

R

-lt-

3uilding:

t5

_

Grsde

t

i;me of lnctdent:

!u r¡tlon of

tncldcnt: tSw,.. I

Ieam members involved
',Vhat was happening immediatelV prior to the studenf s problem behavior (antecedent):
; ght/¡r¡ument wrtn

I

pe€r

Y

!turJent wa¡ oenred oreferred ðcrtvitv or

wart

i,uO.n, was

rtem

!tudent wðr

_

!cudenr was told to move to another loc¿tron

_

.

of ta¡k?

,

itudent was erpected to trensrrion

-

-

-_

ãsKed to

grven ð tark lwhat kind

l¿acher was anendrng to cthers

-

Student lvas prompred to use specúlc reÞlðcement behav¡or lwnich on:?

ltudent w¿r grven one-on-one ålleñtron ldefcnbet

,-ìther:

o

Prior

to restratnt or seclusion,
léom .1"¡, (remove

)]

iet

_

lrm¡ts (rf,

please describe the de-escalation rtrategies rhat were attempted by staff:.

¿uor€ncel

thenl

let

a

X

umer

flrect rc cool down

area

rlffered chorce5 ior cool down

X

r3norrng (not provrding anentron for escalated behavtorl

,:r?r¡ptrng u:e of reolacement

behavro¡

_

tirlt/then

r)the

;tudent non-aqgresslve behavior prior to restrarnt or seclusion:

t\
5tudent oqgressive behavior Þnor to restraint or seclusion:

Student aqgressive behavror durinq restraint or seclusion:

lime out:

3:grnnrng,rrme,

t I ; Z'ì

Ecdingtrme:

lt;39

'rf durðtronexqeedi50mrnutes-ne€ctoarentaoproval,rrparenrrr

¡ravarlaþle, need ¡dmrni¡lrator approval (oocumenl ttrne/approvall

Physical

rlo

restraint:

y' ,",

-

Õ

lvaluðtron, rf ihysrc¡l restraint was used:

)

Children'¡ Control

Y

Positron

Begrnnrng

t,o concerns

X ,.rr

t^e, I Ii ZJ

Ccncerns, desc¡rbe:

-

Control Posttion

!, gnature:

inding

Iranrpon Posrtrcn

rrme: -l!,2-?

 tbe c,ther lnlullet to other studenlr, sr¡rf ünd/or propertv damaqe:

what took place ¡iter time oui

:ribe

- !tudent

re¡tored th?

f
I

;arOan, raturned to wofl( wlth the

r,ro.nt

group

and staff engaged rn ð prwðte conversatron about the behavror

-

,,vril

tatf

meet f ormally at a t9¡¡m to revrew FÈA/AlP lÑleetlng datei

;ording to lhe current

/

FB;A,

time:-l

what is the hypothesized function of this behavior?

placc, see ðoove to documentl
currenil:BA üoes nor AdOreSS rhrs partrcular oehavror {meetlnE must take

(_,""

te¡avior r¡ marntalned bv ascess to ãdult

_'ihrs

anentton

This behavlor ls malntalned by access

to peer ðttentron

ti matntatned by ascape from soctal tnteracllon

:his

benavtor

{-

;ttts

benavtot It matntalned bV eSCApe frOm un'preierrert tesk3 or acllvltler

_

;i'lts

cenavtot rf marntatned bv access to oreierred lteml/actlvltle5

ïhls

cehavlol rt ma¡ntatned ov ¡Lfomatlc retnforcement

-)es this

hvpothesrs match the ABC of this incident?

'ar, out,rnterv€ntton

X

)

Student retulned to gen. ed. settlng

met iniorm¡llv a5 ¡ tgSm to fevtew culrent lntervenllon strategles

_ it¡if
.3

Student transrtloned to qulet ectlvltY ln a prlvate work space

X

task

t

complete;

envtronmenr

iruoent.returned ro worx

-

*.,

o

wðs appropfrate ånd rnstructronal/interventton strðtetles

_./eS.howeveroutrnterventtonmavhðveretnt'orcedthenegattvebenavlor.
¡lo.(nenvoolnegrsd,Jesrìotsèemtom¡rtchthrirnc,rdenr,
-neou led I oleðse cocument tlme and d¡te åoovel

.,il 1 stay

!he same

rheteãmlvlllfevlewther:¡pon¡eolan.

)

Àgcdütðwrll becolleçtedlor5C¡v¡andameetlngto'evr€wtheFBAwrll be

/hât ¡s the desired replacement behavior?
row fnanv minutes of specially designed

inrtrr.tion*.bìffi'o for teaching re placement behavior on thls student's

IEP?

lrnut!5 ãñO !er'¡tçe Orovrder

îr.e
¡

råam wrll need to meer to disçuss aoding mrnutet of sen¡rce ¡lme to teach this replacement behâvlor

¡rent/Guardian
¡

rport

cornplete

\,lethod of contact:

h^$4.-

ldmrntstrator signature:
to thÊ parent/Euardi¡níll
l¿nd coote¡ of råport to; Prrent, 5!udent Cum.ulâ¡lve Folder ar:d Educ¿tlon Services

@
)

 1,

-lJte ot Oocument¡non:

l()\\r..\

Ð

o
5

¡r

(

 

Iy *

(il.lY
tt\

I rata

.t,

lncldent Report Document
and Seclusl on ilmà-Out
log

ludent;

3uilding
6rade:

: rre ot tnctd€nr:

Tr-¡ â

{ llr

,rt 

nl m embers

;;,rr

of

tnoJent:

It

p

luråt¡on of

rrcrdenn llv

r^i

rnvoh¡ed

tvas haopening immediately
prior to rhe student,s
probrem be havior (antecedent):

"vhat
',Chf/argurnent
_
_

tvrth pqg¡

.-

jtt¡den¡ rvðr
ltven ¡ task l!vhð( krnd of t¡skl

v

!tu,Jent Ìv¡¡ oennd preierred
¡Ctrvrty Or ,!em

ituden¡

.-

:tudent

tva¡ itrked to

,,varf

t

w¿r (old to n syq
to

"_

student

w¡i

¡nother loc¡Uon

5tldent wa¡ eloected
to

I

tran!trrort

,

_e¡cher

oro mpteo to use rp€cttlc
Íeplacement behav¡or
lwhich

rvðl dttanotng to other!

one¡

itutJent,,va¡ gtven on€.on-onc
¡ttentton t,,retcflbe;

-r)then

prior,to restraint
or seclusion, please
descnbe the d e-escalalion
s trategies that
were attempted by
staff:
€nce'

O-'Ï-1',,;:veðud

:

;::

ï;,

-L

0,,r., tocooldownarea

rovrding attentlo n for

.Jrompttng use of repl¡cement beh¡vror

_

e¡c¡l¡ted behevror)

Offeredchotce¡forcooldorvn

_

Firrtlth€n

Student
non-aggressjye behavíor
prior to restra int or
seclusionl

q

t

\OY

Student cg g ressive behavi
or oriof to resFaint
or seclusíon:
Student oggressive behavior
durírg restraint or seclusion:

ll¡e OUtl
f..:'/¿tlå01e,

n

I

l.*

:'9gr.nr¡q ¡,¡¡.
J,r
f rr3;ng
'
l3C f ,Jmrnr5¡¡¿¡g, ¡ caro'¿al
( Joîurn
ent

irrne;

lr ).; i= '

ttr',ìe/aooro,/at)i

Physicrl restrårnt:

-

ri utf Cn. i :'i,! :!r,?5¡rlr.:,1.1!,.

j¡,J.

'(

'

'ut .-

,

1..:,.c,,en,s

f juratton txceeds
50 m,_.,¡ies _ te:d
oaren! ¡cprovð¡, .I
ra¡Ent,s

fi¡¡¡rg¡ rositrc.l

,;-;;:",ä:"";l;"::
\.: l:r:¡rrs

_

..ar::r-i,..iesi,

{

"'r.roorr )cs,! /Jn

t , i..,
__J_l¡ls

t.?.

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ce:

_-¡-9i''

 oGrl'?r

:¿icr rpÊ

)1

pro0êf tì' o¡fnng?
r'o;ther ltudef:r5"¡irtt ¡tldior
"!:r¡ftd9

lirne out lvð9 complete
took place ¡fter
what
Desc rrbe
tr ånsrt¡oned
tU

i

r.J

envlronrnent
e nt r?rÌOreo !ne

;tuo ent retuf neo t3 "'rorr

À

Stulent

5iu'Jent'Et',¡rned

i:: rf
5

:c

!ail

o

about t¡e ceþavror
¡n ¡ ¡ilvete coñvel!af'on
;tucent and rt:rl engaged

!llß

wolt w'(n ii€ g'cup

r:t'r¡¡rn¡liv !¡ ¡ :E3m
w,rl

pflv¡te '¡rofk 50ðce
lo ou èt Sctlvrtv ln ¡

re:r i¡rr¡atl.,

tl

lsvr¿w

: .rrent

I

îtErrrenti0n s:Íãleg'Êt

t:me
;ã4, 3lÞ I Ñteåtlng Úate'
a¡ ¡ :?3ñ :1 '?vr¿'¡'

)tler

d functton of this beh¿vior?
the hVpothesi¿e
rvnails
t3A'
current
aco'/e to 'Jocumentì
)cco rdinEt to the
tSke pl¡cE' t¿e
not addresl
ne c'Jr'!n! ;¡A dces

(hrg

acca¡s
-11r9 u¿¡¿vfof 1l matnf ¡tned'ov

\J
rà-

-

'L:t

lo SdUlt lttentlon

behåvrol

É¿rsvrol rr

-hri

oènðvtor rl rnðrnt¡lrìPd

Írrr!

o¿navror

erclpÈ irorÍ '¡n'pr¿felred

bY

,i rrtàrnt¡rned bt/

cehavlol ri

ðcce53 to of etef

at:ent'Qn

(aÊk3

ol ¡c(!vltteS

led rtem!/acttvrite¡

retnlorcement
r¡ttn(¡lned bv ¡utomatrc

malch the
Does this hvpothetls

ABC of this incident?

instructlon¡l /interventton
was ¿ppropf lare ðnd
/e3, oul rnt€Nrlntron

*.

!o ceel
il rñfiñ!ôrnÊd bv ¡ccer3

irom ¡oct¡l intef¡ctlon
fntlnttlneo cv etcroe

ihtt

'hl3

tr'leetlng must
c¡ñlcrlðr cenitvlor

the 5ðñe
!tr¡rteglei lvrll st¿v
plan'
tew fhe response

fhe te¡m wril
the neg¡tlve beh¡vtor'
mav hðve relnforced
In[efvenuon
'1e9, hc'¡revel our
¡nd
f or 5 d¡v¡
d¡t¡ wrll 'oe coll€cted
lhts lncrdent' ¡\ðC
mðtch
lo
reelñ
doe¡ not
reT

ð

o

the tBA rvrll be
ñeetlng to rev'È'¡'

¡lo, lh€ hypothest:

,c

date ðbove)
oocumÊn t 0me and
necrule d (pleðse

behavlor?
desìred replacement
',r,/hat is the

lEl
on this student's
replacement b ehavior
teaching
for
provided
in structìon are
of speciallV tJesigned
rninutes
tnârlV
¡"{¡¡r¡
lJer
.:ilr1Jt¡! An6 5eNlce Plori
,

.r.-

:h:

beh¡v'0r
t'trs r?oiðc€fr€nt
to
u:es oi serurcg !rrîe
mrtl
addirg
"l¡cn
r'neet t? d:9CU5t
le3rn ,v{ l 'e€d lo

t : rent/Gu¿rdi an contåct:
)

1.t., x-''.1'úi ì11n'5tfit:f

ta?rt ::f :ie:eC CV
i rr il:1 Cli'/

oi hÊ

rotor!r-tJtl:g

.:rd :cÊ'er ; f ...'côl!

coli."nlr(eo lc i:e

5

!'ñitiu'€i

A¿vS ol:¡a
lrðfd lri!  Ñrtî'n;r/eg

'rfe¡l
:n ie'v
("'¡ílti' jt''e l t'l?1 Î 791':¡t
ic: ¡lr !4l Sluien!

c¿t

rr: :¿rt.

Í :1":r

ü

 I

fðte of Docu rnenraronr

o

lolv
Ð

Y ll¡¡ll

l-\ B 't 5

(;r'tY
lrli¡llt.'f

lncident Report Document and Seclusion Tlme-Out Log

)

6rade:

lding:

5ludent
r¡teof rncrdent:

ã.ìön

Íime of lncrdent:

.

4z

L'uråtlon of lncldent:

r^nr

rruk\

feam mernbers involved:
,,Vhat was happening immediatelV prior to the studenf s problem behavior (antecedent);
; ght¡argument wrtn

_

: t u d e n! was o enre d oref

irudent

was asxed to

erred ac¡rviw- ofute

m

ltu dent rvas exp€cre d to tra nsltlo

.

n

Teacher was anendtng to cthers

- lwnich one?
ituden¡ rvai -prompted to use rpecúic leglãcement behaviol

watt

- locatlon
3rudent was rold to movr to another

_

ituoent

t

itudent wðt grven . fask (what kind of tack?

oe€l

_

-

,-rth

€

r.r.,a¡r

r;

-ìoom cle¡r (femove

:et

lrmrrs lrf,

,:rtrnpltnq

use

to= Qìc-t*d \qet\- S". q

ho.^,*tr-l

¡rior to restratnt or seclusion,

l7

¡tten¡lon ldescrtbe:

wð5 glven one'on-one

please describe the de-escalation strategies that were attempted by staffl'

auot€ncel

rtmer

5Ét å

Yrnonng

th€nl

X

)irect to cool down

area

(not provrding anentton for escalåtÊd behavlor)

f

chorces íor cool down

irst¡then

-

behavlor ùt

of r:ol¡cement

X:farad

non-aqgressive behavior prior to restralnt or seclusion:
Student

Student oqgressve behavior P!!gI to restraint or seclusion:

o

o

Student oqgressive behavtor durinE restraint or seclusion:

\,\
,l
,¡

Physicalrestraint

æ

t

}ifÆ

:ndhs.me:

?t11

'

lf duratron exceedt 50 mlnutet

-

need oarent aoproval, lf oarent ¡¡

¡a,¿a rla'ole, naed ¡d mrni¡tra tot ¡ oprova   (document tlmê/ð pprovãll

¡lo

J,.,

Children's Control

b: tL Csxa.q¡\ hÞ\ù
?t

fr-

s used:

þtÞ!¡

ro

concerni

Positron Xra.m

legrnnrng

rrme:-

Concerns, descrt be
'rigna ture:

Control

Posrtion

inding.me:

ir¡n3poÍ Pcsrtton

-

 €o*t-'c"-rs

ô{

PP."C

C^

{<c-cr,'a-(

ç\

Ct+

ç!srrc.r- e.r:.1-)

I

'rbe other tnlurles to other students, st¡rf ¡nd/or propenY damaqe:

I
I

I

:nbe

_ _itudent restored thr

_ i(uoent

-

o

what took place aiter time out was complete:

returnect to work

studenr

_ itslf

envuonmeni

StudEnt tr.n$tlonGd to quret afilv¡tY rn a prlvate

task

wolk space

5tudent and ¡taff engeged rn a pnvate conversatton about the behavror

rarurned to wofk wrth the

grouF

3

returned to gen, ad. sentng

met inìormallv as ¡ tsem to revtew curf ent lnterventton strategles

-Sludent

StarfwrilmeetformallYa!areamtofevlewFBA/BlP(fv1eetrngdateitime:J 

f^.Ê

'. \t-.

:ording to the current FBA, what

_ :ne

placc, see aoove
cuf rent ÉðA ilo€5 no! adofe5s thts Fanrcular cehavtor (meêtlnE must take

V':rr,,

Eenavtor

ihis

-yl
-

marntãrned bv acce¡s to adult

15

åttentlon

Thig benavror rs matntarned by access

;r.r,a Þenðvlor

rs

mðrntarned bv escape from un-preierrect tasl$ or acttvttter

ihts

ce¡avtor

15

rnerntalneó bv access to greierred ttems/actlvttle¡

rhts

3eh¿vlol ¡s rnalntalned Þv ¡tJtomatlc relnforcement

",

,,

to documentl

to peer ðtlentlon

benavtor rs matntatned by escape from soc¡al intÊlactlon

-)es rh is hvpothesrs
-t_

is the hvpothesized function of this behavior?

rt,our

o

matcn the ABC of this incidentl

rntervenuon wð$ agpfoDrrate and ¡nstructlonal/inteNentlon stretegles wrll stav the same

e5, ho,xevet

our tnten/entton mav navc retnforced the neBatlve benavtor, fhe team wtll revrew the Íesponse olan'

)

the tRA wrll be
t,to, (;le nyoornesrr rjoes óot lecm to mðtsh thts lncrdent. AgC dùt¡ wrll be ccllected lor 5 devs and ð meetlng to'evr?w

neouled lolease oocument tlme and otte aoovel

/hat is the desirþd replacement behavior?
on thls student's IEP?
ow rnanv minutes oi specially designed instruction are provìded for teaching replðcement behavlor
!¡nut€5 ãno ¡ervtce ofovtder

;þe

team wrtl need to meet

to

3rent/Guardian contact: Dðter

Ciscuss aoding mrnutes

1 - tù'rs

of serv¡ce time to te¡ch this reolaceman! behavtor

;'t.' 6'.{ b
Jdmrntrtrator sitnature:

t.?oort cornpteted
å ¡rntt!ñ cooy ol the leoort r¡úst

be pos tmafkrd to the pafent/Búård¡ðnltl

nt,

:ènd cootes of feDoft lo: Prrenl, student cumulaltve Fold€l ¡nd tduc¡tron Selvices center

O
)

 Date of Documentatlon:

q-u4s

fuffiffi

s

lncident Report Document and Secluslon Tlme€ut

Student:

Bulldlng:

Grade:

Date of lncldent:

Tlme of lncldent:

Duratlon of lncldent:

l0)55

Team members lnvolved:

What was happenlng lmmediately prlor to the student's problem behavlor (antecedent):

_

flght/argument wlth

fi

s,ra"nt

'X

peer

student was Slven a task (what klnd of

- ltem

Student was expected to

was denled preferred astlvlry"or

S,rO.nt was asked to

task?
transltlon

Teacher was attendlng to others

-

-

walt

I

Student was prompted to use speclflc replacement behavlor (whlch one?

-

Student was told to move to another locatlon

-

Student was glven one'on.one attentlon

(descrlbe:

-

I

Prlor to restralnt or seclusion, please describe the de-escalatlon strategles that were attempted by staff:

setatlmer

S-Roomclear(rerou".rdt"n..)

X

Set

llmlts (lf,

then)

Dlrecttocool

down.r..

Xofferedcholcesforcool

-

promptlng use of replacement behavlor

-Student non-oggressive

behavlor prlor to restraint or secluslon:

-1" ù-L7f

behavlor orlor to restralnt or secluslon:

Student

restraint or secluslon:

Student oggressíve behavlor

Time

Flrst/then

lgnorlng (not provldlng attentlon for escalated behavlor)

-

down

out:

unavallable, need admlnlstrator

physfcal

,n:35

Sq .. I tf duratlon exceeds 50 mlnutes - need parent approval, if parent ls
. .approval (document tlme/apProval)l
-

Beglnnlng time

Endlng tlmer

No {- v"r

restralnt:

I

X-cHl¿r"n's

Control

Control Posltlon

Posltlon

-Team
f0'.ÔC

Satuatton,

[0

Beginnrngtrme'
No Concerns

lf physlcal restralnt $ras used:

-

ÞÇo,,,.",nr,

-rX-Tr.ntport

Posltlon

:ås

Endlng tlme:

descrlbe:
Tlme:

-

 Descrlbe other lnjurles to other students, staff and/or property damage:

Descrlbe what took place after tlme out was complete:
Student restored the

envlronment

-

Student reilrned to work

-_

Student returned to work wlth the

Student transltloned

task

to qulet actlvlty ln a prlvate work space

Student and staff engaged ln a prlvate conversatlon about the behavlor

group A
-

ffi

Student returned tq gen. ed, settlng

Staff met lnformally as a team to revlew current lnterventlon strstegles

-

Staff wlll meet formally as a team to revlew FBVBIP (Meetlng

Accordlng to the current FBA what

ls

date/tlme: _

)

the hypotheslzed functlon of this behavior?

FBA does not address thls partlcular behavlor (meetlng must take place, see above

behavlor ls malntalned
-the,cunent
Thls behavlor ls malntalned
_
-Thls

_Thls
_

by access to adult

attentlon

to document)

Thls behavlor ls malntalned by access to peer attentlon

by escape from soclal lnteractlon

behavlor ls malntalned by escape from un-preferred tasks or actlvltles

Thls behavlor ls malntalned by access to preferred ltems/astlvltles

_Thlq

behavlor ls malntalned by automatlc relnforcement

Does thls hypothesls match the ABC of thls lncldent?
Yes, our lnterventlon was approprlate and

lmtructlonal/nterventlon strstegles w¡ll stay the

same

q}

Yes, howeVer our lnterventlon may have relnforced the negatlve behavlor, The team wlll revlew the response plan.
No, the hypothesls does not seem to match thls lncldent. ABC data wlll be collected for 5 days and a meetlng to revlew the FBA wlll be
scheduled (please document tlme and date above)

What ls the desired replacement behavlor?
How many mlnutes of specially deslgned lnstructlon are provided for teaching replacement behavlor on thls studenf s tEp?
Mlnutes and servlce

provlder

-

The team wlll need to meet to dlscuss addlng mlnutes of servlce tlme to teach thls replacement behavlor

reg4^rethod

Parent/G uardlan Conta
Report completed by:

of contact:

Admlnlstrator sl8nature¡
A wrltten copy

ofthe report must be postmarked to the parenVguardlan(sf wlthln three days of the lncldent.

Send coples of report

toi Parent, Student Cumulatlve Folde¡ and Educatlon Servlces Centar

@

 f

¡i. .\

t

t...,rr

rt

irf

..r.dl

')ùte of Document¡tron:

,'.!.ttrl

l()\v.\ (:¡'tY

Ð

@

lncldent Report Document and Secluslon Time-Out Log

Gra

Student:

Building:

Date of tn c ldent;

fime of lnctdent:

leam

Ít;i5-ir.Ll

"

Dur¡tlon of lncldent:

rn embers involvedl

What was

happening immediately prior to the student's problem behavior (antecedent):

t,ght,/ar¡ument with

peer

X

Stu d e nt was denied preferred actlvlty or

itudentw¡5 ¡¡ked to w¡tt
frudentwar told to move

_

t

5

,,ro.n,

w¡re given

ltem

¡ tðrk (rvhat

kind of task?

5tudent lvas er pected to trans

ttion _

Teacher war attendlng

to

o

th

ers

-

student wai proñpted to use speclflc replacement beh¡vior (whlch onel

-

to another loc¡tion

u dent wð3 glven one-on-one attentlon (descn

Other

Prior qo restraint or seclusion, please describe the de-escalation strateBies that were attempted by staff:

Oå

Setlimils

_

setatimer X-oirecttocool downrr.. X

Roomclear(removeaudiencel

promptrng

(rf,then)
use

--

offeredchoice¡forcool down

lgnoring(notprovrdingattentlonforescalatedbehaviort

-tirst/then

of replacement beh¿vior

Student non-oggresslve
behavior prio r to restra¡nt or seclusion:
¡t
t
,: , ;. ,,
,...r

.,.

Student aggressive behavior prior to restraint or

r,

uston:

\ñ

f

Student aggressive behavior durinÊ restralnt or secluslonl

I

,.l

n4

11

ôr4 (,q

b(o cþQ¿

.¿'a?

w7
I

ìÉ¡'

¡

Time

out:

Beginning

tinet tI'"

lS

Endtng

timer I

l:

¡,7

. it dura tlon

exceeds 50 minuteS

-

6 41"o".

{¿t

need p¡rent aoproval, tf parent ls

unavailable, need admrnl:trator apploval (rJocument time/approval!:

Physical restraintl

X.,"

_'/es

_

Children's Control

pgsltion ----_

Beginning

@rrturt,on,

rf phvsrcal restrarnt was used:

ilo concerns

-

time:_

concerns, dercribe:

-

Ie¿m Control posltton
End¡ng ttme;

_

rr¡nsport posttion

v

 üéScrrbe

rnlurlet to other

other

place after

Describe wh¡t took

''

st, ¿

complete:

\

pflvãte converlatio¡' ôbout the behavior
student and rtatf engaged rn a

t¡sk

stuclentreturnedtoworkrvith.thegroup
-

-studentietulng!to,ï:n'cd'setttng
metinformally¡!ateamtofe.,lEwculfentintervenlleß¡tlate8le,r.tr..
-Sroff 9[atf rvrll meet formally

c

qulèt ðct¡vltv in a prlvðte work Space
Student tf ¡nsltloned to

^¡r¡¡r¡na¡nr

nt returned to worh

"

tilîe out was

'¡^ envrronmrnt
re¡rcred" the

Student

-A,

ltuüent!' strtf ¡nd/or pfopefw 'J¡mðE€:

(Mêeting
as:¡ team to review FBA/BIP

',i 1,,.i.,'.:.
-.', ,. ., .:'

date/tlme;-]

Other

AccordingtothecurrentFBA,whatisthehypothesizedfunctionofthlsbehavior?

:r"
f

.urr.n,

;r^,ï,

adult
beh¿vlor ls ma¡ntained by access to

hlr

place' see auovelo documentl
beh¡vior (meetlng must take

;", uo;r.rr,n,;'ilircutar

attenrlon

bv ¡cçe3t to peef ðttent¡on
lhis beh¡vlor lr maintained

fhlsbehaviorltm¡tntatnedbyescapefrom¡oclalintefaction
Írom
f hts bet.rior i¡ m¡rntarned by escape

f h¡3
f

hi¡

behavlof

ti matnt¡lned by

Ûcce35

un.prefer¡ed tasks or rcr¡viüer

to preferred rtems/activitiet

reinforcement
behavror i5 malñtðlned bV ðutomðtlc

of this incident?
ooes ti'rls hypothesis match the ABC

o

wrll staY thc same
and inrtructlonal/interuentio¡ ¡tllate¡rer
Yes, oul lntervention w¿r appropriate

behavior' f he team wtll review the re¡pon¡e Plan.
./es, however oul rnterventlon may have rernforced the negative
review the
collected for 5 dav¡ and ¡ meettn! to
to m¡tch thl3 incidÊnt' ABC data will be
the hypothests doe¡ not seem

No,

thi

will be

]

¡nd dÐte above)
rchedul ed (plea¡e document ttme

rñhat, is

FBA

I

.ec

desired replacement behavior?

behavior on this studeni's IEP?
are provide d for teaching replacenr?nt
¡nstruction
designed
specially
of
How many minutes
M¡^utet a n{

servrce. ProYide.r

behavior
of service time to teach thls replacþment

,.' lh Ë team w¡tl ne"d to meet to discusr
rl

PA

r1Ît1qi*i: n Cont.act: oate:
r''l

.l :S

A

Method of conlact:

llL

¡dminirtratof tlgnature;

Report complet¿d bYt

.,

Tlmer

À lvrr¡tEo coþy

plrent/8u¡rdi¡n(¡l withln tÍiree d¡y¡ of the inrid€nt'
ofthe¡¡pqrlmust.qF?ortm¡rkedto the

Canter
Cumul¡tlve Folder ¡nd Educ¡(ron Service!
:¿nd copler of report to: Palent' Student

t

 Date of Documentatloni

þw

c

- 22-

lncldent Repo Document and Secluslon Tlme-Out Log

Student

Grade:

ildlng:

Date of lncldent:

4- Lz- IE

ïmeofrncrdent

Duratlon of lncldent:

Team members lnvolved:

What was happenlng immedlately prlor to the studenf s problem behavlor (antecedent):

Teacher was attendlng to others
Student was expected to transltlon
-flghVargumentwlthpeer.vlstu¿.n.wasglvenaask(whatrtnaoro,rlf
_ Student was denled preferred actlvlty or ltem

_

-

-

walt

Student was asked to

Student was prompted to use speclflc replacement behavlor (whlch one?

-

Student was told to move to another locatlon

-5tudentwasglvenone.on-oneattentlon(¿"sc,l¡e,l
Prlor to restralnt or secluslon, please descrlbe the de-escalatlon strategles that were attempted by staff:

C-Roomclear(removeaudlence)
Set llmlts (lf, then)

setatlmer

Dlrecttocool downarea

offeredchslcesforcool down

-

-

promptlng use of replacement behavlor

-Student non-oggresslve

Student

Flr#then

lgnorlng (not provldlng ottentlon for escalated behavlor)

behavlor prior to restralnt or seclusion:

\

beh

f

restralnt or secluslon:

Student aggresslve behavlor glurlns restralnt or secluslon:

ì
Time

out:

Beslnnlns

tlme' I l:

15

Endlns tlme:

[t:-S, 0 r lf duratton

exceeds 50 mlnutes

-

need parent approval, lf parent is

unavallaÉle, need admlnlstrator approval (documenttlme/approval)

Physlcal

No !L v.r K

restraint:

sr.tr.tton,

Beslnnlnstlme

lf physlcal restralnt was used:

No

-

concerns -

K

con..ts,

5C

Control Posltlon

ctrtUr"n's controlPosltlon

-Team
t ll"3-2t

Endinstlmer

I

Tranrport Posltlon

l:2\

descrlbe;

Slgnaturel

Tlme:

-

 DescrlbeotherlnJUrle3tootherstudents,staffand/orpropertydama8e:

Describe what took place after tlme out was complete:

envlronment
Student returned to work task

Student transltloned to qulet âctlvl'ty ln a prlvate work space

Student restored the

-_

Student rcturncd to work wlth the

_

group

Student and staff engaged ln a prlvate convematlon about the behavlor

\,/r Stu¿ent rrturned to gen, cd. rettlng

O

- å

Staff met lnformally as a team to revlew current lnterventlon strðte8les
Staff wlll meet formally as a team to revlew FBVBIP (Meetlng

Accordlng to the current FBA, what

_

ls

date/tlme:

ì

the hypotheslzed functlon of thls behavior?

the current FBA does not address thls partlcular behavlor (meetlng must take place, see above to document)

attentlon Thls behavlor ls malntalned by acce
behavtor ts malntalned by escape from sbctattnteraetlon

Thls behavlor ls malntalned by access to adult

-Thls

peer

_î:,:::::":::::::"i:.:ï....ïï:;::,,il¡e'iv'[es

_Thls

behavlor ls malntalned by automatlc relnforcement

Does this hypothesls match the ABC of thls lncident?
Yes, our

I

lnterventlon was approprlate and lnstrustlonal/nterventlon strategles wlll stay the same

Yes, however our lnterventlon may have relnforced the negatlve behavlor. The team wlll revlew the response plan,
No, the hypothesls does not seem to match thls lncldent, ABC data wlll be collected for 5 days and a meetlng to revlew the FBA wlll be
scheduled (please document tlme and date above)

What

ls

the desired replacement behavlor?

How many mlnutes of specially deslgned instructlon are provided for teaching replacement behavlor on this åtudent's

IEP?

Mlnutes and servlce provlder
The team wlll need to meet to dlscuss addlng mlnutes of servlce tlme to teach thls replacement behavlor

rc

Parent/Guardian Contact:
Report completed by:

lo9

of contast:
nlstrator slgnature:

A wrltten copy of the report must be postmarked to the parenVgu¡rdlanls) wlthln three day¡ of the lncldent,
Send

tol Erent, Student Cumulatlve Folder and Educatlon Servlces Center

@

 -ì.lte ot Document¡tto

.Èl

s

ln

5ludent
--

dent Report Document
a nd Secl uslon Time-Out
Log
lding:

tte ct ldctdenr

Íeam

r()\\,,\ (jr.ry
{ rr4rr rrr\trr¡.r.

:H

Grade

i ;rr sf ¡¡q¡¿g¡¡.

rn embers lnvol,red:

',t/ha t was haope nrng immediately
prior to rhe student,s problem
behavior
I ,,v,th

.ttrdent

,vðr

itudent lv¡r

Ë-

n

luretron of lncldent:

eeer

X_

lent:d oreierred

acUvrtV

rsked:0.,v¿lrr

*_

,,roun,

or,tem

rvas grven

.-

(a ntecede

¡ ta¡k lrvnar krnd of t¡¡k?

str'Je nt ,,vas e.roecled
to (¡ans¡llon

ieåcnerrva5 ¿lrênolng
ro others

itu,:ent wå5 promoled to
use 5pectilc repl¡cement
cehavtor
- lwhtcn one¡

it''rJent rv¡! lüld to nlcve to ¡norher
locatron

-_
,J

Jtudent trðs gtven one-on.one
¡tten!ton tde¡cfi

lhe r;

Prior to restratnt or secrusron'

prease desc.be
the de-escaration strategíes
that were a ttempted
by staff:

'ìoom cie¡r lrÊmove aud¡encel

!et

f-^-

jet ¡

trrnrr¡ {rf, lþenl

tlmer

.gnonng

Drrect to cool down
¿rea

0ffered choices for cool
dorvn

(not provrding ðttentton
for escal¿ted behavro rl

-

iromptrng uie of ¡epl¡cemen! behâvtor

_

Firrtlrhen

orh€

Student
no n-oggressive behavior prior
to.restraint or seclusion:

tu{ent
jtud

to restraint or

clusion:

I aggress¡ve behavior duJinq
restraint or secluston:

-lr'1e
:,/t

behavior

0utt

råC 9,

teg,rnrng , -r,17,. (\ ?
o'n*,,...'f'7.L.f ' f :¡ra:.cn
-â9C:Jî,n,5f¡3,, '.--:
lr Jcotc'/¡r r.lcc.rent l r":e/¡o9tc,/å¡i:

r"ys;cal restrarnt:

."--

.i

_.1;-,c,¡n

s

i¡r:.:i lt¡,i:on
ì

.,.--\

:v

n. -g

-

e\c-.eds

i0

¡,n,.1::s _ f :eC Jar:n:
3aor?v¿r, .f aar€nt:s

ie ¡rn c2nìrcl

\)
-r¡7,',

l"

):j

:,?r

::'::l:,r-¡j

)( -, rrrro.: )r!, Ì r1

u3

 .lillt Jnd/or pfooertY 0tm¡ge
to cthÛf gtudentS
'rtlu¡'dr
Qßn€f
:¿SCrlbe
out was complete:
\'vhat took place ¡íter time

Jescrlbe

'l- ,,, o nt
"

f

!iu'Jent

_

?!urî¿d to'rror¡( ¡a¡ß

:tner

Înt

wrtñ
'¿1¡rned i0 "vof\

Staltr'¿'rl

¡¡g¡

i¡rmally

a5

ñe c!:r:n(
-h,s

engaged rn a

ðbout the oehavror
e.ver! converlatron

o

group

!f levrlw ct¡lrent lntelvent'on

st'3tÊ91ÈJ

Ê¡Ai 3ìP l\l??tlng
å:¡årì1 lJ f?v:vr'

l

óat€'trmer

(meetlng musi ¡¡ke
(hl5 !antcular benavlol
ddrers
a
ncl
dces
F¡A

(o
n:¡lntrtñect'Þv accê13
'JêF¡viOr r!

:hi5 beF¡vlol ri lrðlnt¡lnect

t i'

irurenr and sr¡fi

function of this behavior?
hvFothesized
is
the
rvhat
to the iurrent tEA ,
plac:' tee aoov e to docurnentl

rccordinB

\,/

en

rrlt;riotrrârl./ ¡r ¡::3m

it:tf

æltuJent

""r

t*":ll.:
tt ¿nvrronr
r?!!creo rne

i:udent

rpðge
tc'ttvrtt rñ a pfrvûle "vork
tanlraoned lo ouÈt

oY esc¡p€

-'n

¡dull lttentlon

! !ehavtol r5 rn !ln!alned

geer åtlentlon
by ¡ccets qo

irom ¡octal 'n¡er3ctlon

tatkt ol lc(lvl(lei
bï esclpe irom'.rn'prelerred
:!ì t! oenavlùr ls rr,¡¡nttrned
prelerred rterñ¡/acttvttte¡
bY ¡cce5! ro
cen¡vror l! rrðrnt¡lned

rhls cenðvrol t¡ malnt¡tned

-'hti
loes this

_L

bV

¡utomattc retnf orcer¡ent

the ABC of this incident?
hvpothests match
appropf l¡¡re ônd lnrtructional/tnterventton

c

the 3ðrne
str¡tegres r,vrll ltav

plan'
w¡ll revtew the respon:e
oahavlol' fhe leðm
neg¡tlve
the
rernforced
be
rnlervenllon mav have
revrew the FBA rvrrr
'/ e9, hcwevel oul
and ð meeanB to
f or 5 davs
co*ected
d¡ta lvril be
thls lncldent' À8C
not reem to match
)lo' rl'e hvPothe st¡ doe¡
i/.
,;
dote abovel
t:-.
(pleale oocum ent trme and
-i.tir'l'1.
¡cn eouled

/,:5, our Interventlon

'l,¿¡É

::i.

'l/hat

behôvior?
is the desired replacement

¡6r¡

inst
sP eciallY designed
rt1ðrlV mlnutes of

student's IEP
l:'t
\-.
behav¡or on lh is
rePlacement
ng
i teachl
n are prov rd ed fo

l,

ttte
r 1¡3¡t/Guardian Contacti
?

-r:f rt ::nc

Ctlcus5

¡'Jdiig rrrnute¡ oi

nJdE

¿.

r.,(., I

prOvrdef
',lrt',.¡133 and lefl/lCe

-.:e r?rm ,vrli ^eed lO n"eei

sen¿rce

reoì¡cement oenåvlcl
!!rne lo f E 3Cn tnrs

tf(

.','.'3'

.,.etrod

.vr

li:n

tnri!t
¿:o', oi :¡e reoort

::

'o ccorer ol

:i

.:ontact:

,\':mlnr5tr¡tf f ! lnAtUre

?:?d

i

(-tt

Je

cot(f

r:¡olt lol ¡3rert

Jr rld to ine
5:

rhr€e iavt ¡f t¡e ¡¿'ltnt
cðfeñl/lu¡rd'¡rltì ù'l1ln

' lent C,¡m,,:tirve

Ëo,det

rrd ijucarcn

i¡r' iêr ::l(:l

@

 -l¡te oi oocumentðtton:

'.'}Ð

o

S

¡()\\,,\ (j¡.ry
" rr¡tt{ rrr\rrrr¡'r

:ã

lncldent Report Docurnent
and Secl uslon Tlme-Out
Log

luden t

Suildín

:!te ot lnçlcrn¡i

6rade

i",Tc of tnctdEnti

-'ir¡tron of rnc¡dentr
Iu!

ILì lYui \"t

tft m e mbers rnvolved:

ët

,,!,hat

rvas haopenrng immediately prior
to Ìhe s tudent's problem
behavior (antecedent):

-gnt/a¡gumenr rvrrh
cee/

-_

(rruo"n, !vð3 gtven r tð5k (tvh¡t

.tudent wð¡,enrrd o¡eíefted

,
_

5ludenl wåt ¡lked to

ittrdenr

rv¿¡

rrem )Á,

ðctrvrty or

,,vðrt

--

krnd of

dent lvas e¡oected to

t¡sk

tr¡nstlron

, ie¡cher lvðr ðttandlng to others
iludent tvðs oromptect to
u5e rpectiic rept¡cement
beh¡vrot (rvhich one?
t.

,

told to n ove ¡o ¡nothe¡ locJüon

ne.on-one ¡ttentlon
tde¡c¡¡
tJ

v

lher:
-:tu

Prior to restrarnt or secrusron,
prease descnbe
¡he d!.escar¡¡tion strateg
ies that were attempted
by staff;
.loom clerr
lremove audtencel

let trr¡rr¡ (if, thenf

O._

5el

:--

Drrecttocool down¿rea

.

orreredchotcesforcool

'3n0nng lnot provtdtng
attentton for ¿scalated
behåvrorl

i_

prorñplrng u¡e of ¡epl¡cement

¡ ttmef

behðvlo¡

_

dorvn

Firrvthen

O

Student non'oggresslve behavior
prior to restraint or seclusíon:

Student cgqressive behavior

5tudent oggres

clusion

f

-'31ìp .,,r:
¡c.¡.

i:g:nnrrq t.r.¡

,.eeo ¡c,î,n,5r'ä:or

.e',

i:r..t:ãl

!(.r, a!

Yr1

ll _ í.,r;.r r.., â)tt

l oorovål lcacrr.ent ilri e/ aao¡av atl

,3hysrcal restr¡fnt;

:t1i\àlt?-,

to restraint or

behavio r durinq restraínt
or seclusion:

k\
,ii ¡vð,i

o

to

.,.r'is

{'r,

!,

S[-.

-

. .. ¡,.
¿! r¡t:on

o,*,¡ ccr:rcr po¡¡:,r;l

exaiedS

V

i0

r-lrnutes

-

'rr-iâ-:r2l

â,F

riegd orrenf ücorov¡1,
,f :¿¡ent ,¡

o-r . rn

:'d -E:

\r/

';r!ccr: ooi,Ì.tn

-r, J: Þ7

 l¿icf lbÈ o(,å"r'ult"'t¡

to cther Étudènts'

oùmðgel
1i¡tl Jtld/or Ërooer$' 

out t'¿as
took place ¡fter time
lescrl'oe what

complete:

t?rtofeo tng envrronmenl

iturJent

it,¡dent

r?tuf !'ec !o

-iiu'Jent 'eturned

iluJent tr¡nrlt:oned

¡ plrv¡te worß

50¡ce

o

ðoout ine oeþavror
rn a trlva(e cgnvelsatlon
engaged
rÌ3rf
ånd
st'Jcent

t35K

"rofl(

n'J' !¿tilrlg
StJJent retulneÚ tJ ien'

wrttl tne group

r¡

tO f,uiÈt åCtrVr(! llt

"'Jo¡1

:èÐm tf rev:'w ct'frent
:r¡rf rr¡t,"¡¡¡r¡llv ¡¡ 3

lnteni ent:on 5!:¡reX!el

i3A/3lP !lvlêÊtlng dale/trm
i¡rm¡riy as ¡ ì'3nt ¡¡ '3v':w
rre:r
itaii'¡rrl

IrFerl

functton of th¡5 behavior?
is the hvpothesized
what
tBA'
current
to the

.Àcco rding

:ile crrrr^t
'hrs

\,,,

åootre to ootumentì
mu ¡t take 9l¡ce, see
benavror tme?tlng
rarÎlcuiaf
thlt
ðddre3!
F3A úceJ nct
¡cce55 to:eer at:?ntlon
'F i oÈnðvrgl ¡ rn¡ ntarned oY
¡durt lrtenllon
li rnårntSrned bv åçcrrs to

c¿þlvfol

oÊ¡ðvror

-L:!ìti

li rnðrntlrned

bY

t¡sk¡ or ùcllv'tlet
etclpe irom un'preierred

:teñs/åctlvrtleg
þV ðccer3 to orelerred
cenðvror t¡ ll1ðrnti¡lne6

rhl¡ ieh¡vrol

-Thr5
)oes this
'\.,'

l5 n'larntùlned bv

¡utomatrc rernforcement

ABC of this incident?
hyporhesis match the
5tr¿te

Appfopllðle ¿nd rn¡tructionel/inter'Jentlon
'/¿5, our rnterventlon w¡3
the negative behavtor'
mav h¿ve rernforcèd

'/e¡, however

c¡ur

lnteilentlon

eesm to match

llo, the hvpotherlr doe¡ not
trme and date above)
,:neduled ( oì.rra'o"a"ttnt

thl¡inclds¡¡'

't/hat

behavior?
is the destred replacement

¡¡¡¡

ecis llY dest
rnanV minules of sP

rvrll be
to revrew the FBÀ
for 5 dðvr ðnd a mee¡lng'
collected
be
lvrll
ABC d¡ta

I

I,I

IEP
behavior on this student's
ing replacement

',:,t'ìu!:5 and rervtce orovrder
-.'ìÉ

i:¡rn'¡¡'ll reeå lo

rnt nu:g¡
rne?r to drscu:5 adding

rir-êi

c¡rent/ Guardian Contac
ì

rcJlt ::îi

';:ì:.:::,,::i*.re,p.nse.an o

oi

5ۖ/rcg !:rr,?

3:M

benavror
lo l:¡cn tn'3 14olãcement

\relhod

ri ::nt¡ct:

.i,ir.lnt5tl¡icr 5 lnalurei

eled tV

Íust;e
¡ xrrìlÊl ::PT :l :"g ftScft
:.¡

ccpret cí r.?tOi( ìOi

r(¿d tc

Àrihln rhree J¡ï!
if? oclê'ìll'l'J¡rd!¡n{tl

-:,Jr'c¡r:n l¡l'/
'.sLr¡il!e io c¡r an'j
i1 rt.,l, Siuden(

ce9

)l:¡e

nc

danl'

:en:!r

I

 n-zz- r5

it.

fate oi Docùrnenteilon:

o

lO!V,\

(:l'tY

Y llthtt trtâtNllit.

lncid

)

Seclusion Tlme-Out Log

Student:

6rade

l¡te of lncrd€nt:

l'irne of lnctdenr:

Ður¡tlon of lnctdent:

t3

n\l ñ

ïeam members involved:
',vhat was happening immediately prior to the student's problem
behavior (antecedent):
, ght/argument

_

wrrn

pecr

: t utrent wðr oenred oref erred ac¡wltv or

'

-

itudent wa¡ asKed to walt
iruclent

-_
,-r

3

,.va5

jtudent was gtven a task (what
kind of tajk?

_

tt:m

.

rvas expected

)lt,uoant

iludent lvås promptect to

to transrr¡on

ïeacher was ånendrng to cthe'

-

use specúlc reolðcement öehavior
1wnìch oneT

told ,o rou, to ãnother locãüon

itudent wà¡

gtven one-on-one a!¡ent on

I

the r:

prior to restrarnt or seclusion, please describe
the de-escalation strategies that were aüempted
by staíf:.

J\-ìoomc!€årlremoveauolencel
=

:et lrmlls f lf,

lhenl

ictå

rlmer

xr'raa,tocool

ctownafea

'gnoflng (not provrding anentton for rscalated
behaviorl

r)the
-_ ,lr?rnpÌrng use of reolacement behevtor
jtudent non-oggresslve behavior prior to restrarnt

_

offeredchorcesiorcool down
rrrstl¡tren

or seclusion:

Student øqgresstve behavior p!g.¡ to restratnt or seclusion
Student aqgressive behavlor durinF restraint or seclusion:

*
lime

out: i:grnnrng,,r., 3j2'l

:rdinl

ttme:

3,,"1

I

'

¡¡¡'¿arlable, nred ãdmtnr5tråtor aogroval (document trmc/approval :

Physical

@

¡lo

restraint:

V ,.,

rf pþ,¡5rç¡l restraint

r.,/as

used: Xrlo

concern¡

minuq!!, need o¿rent aoprÖvil,

¡f

oarent rr

positron

X r.r, control posrtion _ ,rinspon pcsrtron
Segrnnrng t,,"n., 3.' 2L
inding trmel 3 :
L1

children's conrrol

-

lf duratton ¡xcee6r 50

Ccncerns, descrr be:
!: gnature

-::-?i

,

 rnlurres to other studÞnts' stoff

te other

¡nd/or pfoperw damaqe:

c

t'

complete:
what took placl aitel time out was

rbe

*nr,,)nttni

-irudent

restorÊd ,r,a

(¡ruoent

returned to workr

tatK
task

. itutlentrelurnedtoworl(wrth

it¡ ff

-

the

O'

Student transrtloned

X-âr-

to qulet ðcrlviw ln a private work space

ðbout the behavtor
;tudent and 5tatf engeged ln a prlvate conversatton

Þ

returned lo gen' ed' se$lng

group

current lnterventlon stralegles
mel lniormallY as ¡l te¡m to revlew

-Student

wril meet formellY as

3latf

a

team to rev¡ew FðA/AIP ([vteetlng datei

time:'

I

ordingtothecurrentFBA,whatisthehvpothesizedfunctionofthisbehavior?
:ne cuffent laA itoes

(meetlng must lake place, see aoove to documentl
not adoress tnrs pantcular oehavtor
This behavror ls malntalned bV eccees

to ðdult attentlon
benavlol ¡¡ marntatned bY accers

-'ihrs

flom ¡ocial tnteractlon

;h¡5

benaylor r¡ ma¡ntatned bv €scape

,,.r,,

from un'preierled t¡sks or acrlvltles
benavror ls malntalned bY escape

;hl3

tq oreferred ltem!/actlvlllet
benavlol lr mðrntaln€d bv acce55

rhrs

rernlorcemenl
rehavrQl rt rna¡ntatned oY ¡utomðtlc

?X
-

to Peer altentlon

-les this hvpothests match the ABC of this incident?
t /
- --- and
--r '-"'"¿rranrl/ìnrêrvañtlon
lnfiru.tlonat/inl€rvÉntlon
X '. a!. Ður r,rterventlon wðs a'pr'g.ate

t
stav the same
stralegles wrll sta,
stralegles

)

../es,howevefourlntefvÊntlonrñavhav€rernforcecthenegalvebenavtor.rheteðmwlllrevlewthefesoonseDlan'
ABC,Jüt¡'¡rrrrbeccrlectedfor5d¡vsand¡ntee¡l'g!o'evtewthetgawlllbe
,..ro,(nenv'ornesrsooesnotreemtomatchthrsrnc¡den!.
aoovel
lgleã5s document tlme and dùte

ã,"0

r/hat is the des¡red replacement behavior?

low

are

rna nv minutes of specia

i,'l¡ñUtêÉ

and

Servlce OfOVrder

-be

t93m wtil need to

r:rent/ Guardian
:¡port

on thls student's IEP?
rov¡ded for teachinB replacement behavlor

mtet to

Clscuss adding mlnutes

of servtce tlme to te¡ch this rePlacem¿nt behavtor
\¡ethod of contact:

Con

rstrator !ignature:
compteted bV
thc parenvNuardi¡n(ll
:¿ncl c6olet

ard lduc¡¡ron Seruice! Cènlgr
Prr€nt, 5!udent Cum.ul¿¡rve tolder

t
)

 fb-23-rs
fate oi Oocumentatron:

o

l()!V,\ (:l]Y

rt Document and Seclusion Tlme-Out Log

) €
5

tudent

Grad

ng

l¡te oi lncrdent:

rá of lncrdent:
FlrãÉ ù^z;' iime

4,c,

Dur¡tlon of tnctdenr:

nu \qg

feam members involved:
',Vhat was happening immediat
t ghtTargument
wrtn

the

p€€f

_

behavior (antecedent):

jtuclent

-

w¿¡s grven e

task lwhat kind of ra¡k?

_

 

.-studentwaiexprctÊdtotrâns¡tion

-:tuden!wa¡oenledoreferredacttvityorrt:m
itudent lvas plompted
- ;cudent w¡s asKed to walt

wasrnendrngtocrhef,

onel

to use specúlc reolacement Þehavior
-Teachef
lwnich

l

!cudent wa¡ told to move to ànother loca0oñ

-_
,-r

I

itudent,¡rar gtven one-on-one ¡lten$on

tdescrJbe:

{.-rt

tl.e r:

Þ

\sÊ-

\"q\

t( s.C$.o^¡ r Q{.abl¡ ¡ å-

P

the de-escaldtion\ttrategies that
ioom

)

iet

_

cleãr lremove

¿uolencel

lct

lrm¡ts (¡f, ttrenl

å

tlmef

rgnonng

.;r9rnptrng use of r:ol¿cement

behavror

å" 'ffiànrfta.d

tirect to cool ctown area

*nncs"".¡

Dffered cholce¡ íor cool doÌ,vn

Inot provrdln6 anentton for escalated behaviorl

_

Frr¡tlttren

r)ther:

itudent non-oggressive behavior prior to restra¡nt or seclusion:

\.ss (

CÐn

5tudent oqgressive behavior p.!.g! to restraint or seclusion:

çk\

ôk\.

Student oqgressive behavlor durins restraint or seclusion:

ç

tal.CX;.r.1
.

lrne

OUt:

3rgrnnrng trme

:rdlngtrme;

q,98.

'

.¡r¡'¿erlable, na€d ¡dmrnistr¡tor aoproval (document trme/approvalll

Physicalrestraint:

ilo

I

!11

children'¡ control

-

@
nt t¡/a9

Co

ncern

c

lf duratton êxceedr 50 mlnutes

Pos¡tlon

3egrnnrng,,..'
s

_

l\<rr

Y.

\)q-\\
- need oarent åoproval, rf pðrent

ra.a control posrt¡on

I tJ3_

ãnding

rrme;

irnnspoß pcs,trcn

- qB
B:

Ccncern¡, de¡crrbe:
5 gnatura

rÍ

:¡€l

 It

:l

þ.:4.
JE <>rher tnlurres to

'rb e

.i

what tobt place ¡iter time out wal complete:

:r.¡

ff

jtl

)

itu(,entand¡taffengagedlnapflvateconvefsatlon¿boutthebe'havtor

return€ct to work task

- ;tudent

o

'.&

space
Student transrtlohed to qute¡ ¡clvìtv In a private work

Studenl restored ¡h€ envlronment

!,,ro"nt

'TíJ

other studentS, slsrf i¡nd/or proFertv damagel

,,

Student returned to gen'.ed' settlng

letulned lo wol[ wtth the group

-

ent lnterventlon s¡rategles
met lniormallv a¡ a teãm to f evlew curf

;talf

wrll meet lormallv at ð !eam

lo revrew ÊðA/BlP (lvleetlng dalei ti

ri

ording to the current FBA, whaÌ
:r:e cuÍenl
\

/ '

\r

FAA

¡arrbenavtor

rs

'Joes

is the hypothesized function of this behavior?

must take place' ree ðoove to documentl
not addfeSg thts Fantcular oehavtor (meetln8

matntatned bY acce¡s to adult

attenùon

This behavror

îhis

social interactlon
tenqv,o, ts rnatntatned bv escape from

;htr

tasl$
benavlor t¡ matnta¡ned bY escape from un-preierred

-

ihrr

ltemJ/acllvltle5
cenavlof l! mâlncalned bv acÊes! to oreíerred

-

îlrrg ¡ehavlol

-

rs

rs

malnta¡ned by access

to þeer attentlon

ol ¡tcllvltles

o

malntalned oV tl'¡tomatlc relntorcement

- this hvpolhests match the ABC of this incident?
)es

x

stav lhe same
and tn5truc¡tonau¡nren entlon strere8les wrll
es. Ður Interyenüon wås ðopropfl¡¡te

the resoonse plðn'
the negatlve benavror' rhe team wlll fevlew
es,howevef ouf Interuentton mav nave rernt'orcad
lhe FBA wlll be
to
ABc,J¡t¡ wrrl be callected for 5 davs and a meetlng 'evrew
l¡o. (i.re nvoo[ne5r' doÈs ñor reem to rnatch thrs rncrdent.
loleãse document tlme ¡nd date aoovel

)

,,

-:¡eouled

Vhat is the desired replacement behavior?

{ôw manY rninutes oi sP

behav¡or on thls student's IEP?
inslruction are provided for teachinS replacement

,'l¡ñut€9 ànd Servlce Orovrder

Íhe
P

behavtor
mlnutes of se¡¡rce lime to teâch this reolacement
te3m wtll ¡,eed to rneet to clscuss aóding

rrent/ Guardian
:¡pott

Conta

comoleted

b :3()

c^- c^-Qe

\¡Éthodofcontact¡

nl!tlàtor tignatu
rhe parent/:uðrdiðnf

tl

]¿ndcoote¡ofteportlo;P¡renl,5(udentcUmul¡trveFolderandEduc¡t¡on5a¡vicescenter

ffi

 JJle ot Document¡tron

Èl
9l

Q-''¿z--tç

lO\\"\ (.'l'lY
{ [r \4 ttt\t trlr.r

lncident Report Document
a nd Secluslon
Time-Out

ü
5tuden

l¡re
Tç¡

3uilding

or tncrden(i

3tÍl

ii,t

Grade:

g ef ¡¡ç¡1¿6¡.

lur¡rronof rrcrdenr:

m embers rnvOlved:

',ì/hat rvas haopenlng rmmed

to the studení s Problem
behav¡or (antecedent):
itudent ,,vð! gtven r lask
f,.vnat rrrnd of

Itudent rv¡¡ renrÊd oreierred acuvrty
-or

iludent

-*

war ¡5¡ç6 ¡s.,v¡,¡

_

rtrm Jârro"n

t¡¡kl

rvar è.\oecred ¡o (ra nttnon

. ieacner !vð, ¡ttenotng to other5
;t'JJent tvð! prcmoted to
u5e tpec[lc replðcement
þehav tor (whtch one?

itudent rv¡t told !o move to ðnother
locJtron

-

!tuden!

',var grr/en one-on-one

t\

'Jther
-

o

OC

¡ne

5;

Prior to restraint or seclusron, please
deScrrbe the de.escalation
strategies that were attem
pted by sraff
'loom cle¡r
lremove

__

¡udlencel

!et lrrn¡¡¡ (,f,

iel ¡

grrecttocooldorvnareã

trn,er

¡hen)

,gnoflng
(¡ot provtding
_
.":rornpttng ule of replacement behavtor
0ther:

¿ttentton for èrcal¡ted
b ehavrorf

. Offeredchotçe¡forcooldorvn

.-

F¡rttlthÊn

1ñ

student
non-aqgressive behavior príor
to restrüint or seclusion

Student aggressive

be havior

yl¿ g ,rt

to restraint or seclusion:

jtudenr aggressvs
behavior d_gti¡g resrraint
or s eclusíon:

þi
"irne

'I /å, !J

out:
e,

.: r,'7s;ca

3eg ^¡,¡o rre, lâ,.1f_
Jntlr.E ,.n*
r?:ã :df .nr5¡:atar
tolro,/¡l (1cc,.ra,r¡ ¡;¡ :/3 rorrvai):

I restrai

ll):2t\ '

n

ti

i5

  .. i:

 '"/¡i'":3J

j':,¡ì'or

:1:n I i:::,:r cc¡.f:î,.ì
...

a-l

r

-..1,r-rn4 .

irc?ed5 i0,_r,-,.t3r r:go
3ðre'ìt a3orc.r¿r, i l¿rent
f

-¿tm

.-,

;0:

'l

Cci:roJ )t:r:.15

_

!.

'r"t3?r: Dti,:,c,1

í'.r -s: -r,
-/I    ,1
,,t

'¡.,

'<¡ ;
,l{-.t. ..,s¿

 ¡rtlurt¿3 tO ùther

'¿5Cf lÞE (f !n:r

tluden$' lilf f xrldi or

PrOOerf\l OJm¡{e:

glace ¡fter time out rvas complete:
, ^r,v¡r¡ tvork Sgace
lescrrbe what took
qur¿t activrtv tn ð prrv¡¡re
trantaoned to
r
æstudent
ftstorao tne Invrronrnen
!.1

:iuqJent

,/

r¿turned tc

;tudent
!

:

Jen¡'tt''t¡ed

--u

itali

w'rl

ine

rs r¡¡Qr\

¡:¡¡m

ll

:d' !e(!lrg

SirtteSleS
revl:w cl¡flent ¡n''en/¿nllon

-

ne:t ilrmatlv åt ¡ :r¡m t! '?tr:'¡/

:tnar;

¡ccording

St''ãent relurneu to iân'

gtoup

"vr(n

r,.it'n¡3rr''a'lv Jl

ir¡tf
-'

"vorr

{)

tar*

rvhat
to ¡ne current FBA'

ts

Ë34/åìP

l\ter(lng

ú¡re/tlme'

)

of this behavior?
the hVpothes¡¿ed tuncrion

Oo"tnentl
l¡ke plðce' see ðoo'¿e tc
cenavrgl lrne?ung íìur!
cantcul¿r
tn;l
not ¡ddte¡¡
:i-e c'Jrr:ô! f 3Å 'Jcer
teer ¡tt€nl'0ñ
lt rnaln!alneo bY lcce!s !o
'*''
oY àccett t3
Een¡vror rt ff ðrntlrned

¡dult

behavrol

¡tr?ntÌon -

-\L-t1rI
,..t'

,-lìlÉ

-hrt

oÈnavlor l5

rnôlntllned

bV

t¡¡k¡ of ¡ctlvl(les
etclOe irom un'prelerred

rterÍt/¿ctrvrtre¡
oY ðcceiÉ to oreferred
ctnavrol 't lflalnti¡lnect

rernforcement
:hl5 sehavrol r5 rnalntðlnect bv ¡urom¿tlc

e¡ this

Do
,

of this incident?
hypothesrt match the ABC

/¡5.

rr/

w¿5 applopll¡te ¿nd rnstructtonal/'lnteNentlon
"fuf rn¡erventlon

o

same
strðtegre3 lvrll ttaY thê

o¡¡ri'
wrll revtew the r€5Foll5€
0€n avror, Ihe le¡m
retnforced the neg¡tlve
have
rnåy
the FBA rvrll be
'/e5. hcrvever öul lntervenrlon
ånd a meetlng to revre'¡'
be cotlected tor 5 davs
lvrll
d¡t¡
AtC
incldent'
not seem to match thls
)lo, tne hvPo¡he¡t¡ does
abovel
'rf
t trme ànd d¡te

:cñêouiêd

(Pleare oocumen

,'1

',\/þåt

behavlor?
¡s the desired reP lacement .'lLt

-lo,¡/ tnanV minutes of
t.

ir
are
sPecrallY d esigne Liifstruction

J!?t anO sen¿rCe

-,? lt¡rri Jlll nerC lo
)a.e

behavior on this student's
for teaching f eplacement
P rovtded

nr/Guaroian Contact:

lt '?e !

to

J tc!55 addrng mrnutes

'
oo.r,'lt f.

i-l''

oí

Senrrce trme

I ¡r i(¡1 :::ï
::¡J

en¡v'cl
¡ch (h!s reo¡¿cemen! f
'-,) i,

:tg

tJi :lletÌ'

1.,,

"'¿tioo
lfYll1r5:í:¡tcr

5

gnat!lÈi

lo tne t¡fent/gt¡¡fÚl3l¡ tf.x
cl t'e feoof(;ru5t'¡¿ to!tmJr'ed
C:O¡ei of feporl

t

cf icnt¿ct:
..

:::rt::rE'eì9d

IEP

5: J3 ent

t¡li

irr¿¿ d¡vt 2;

''e r'

::,11

jJc¿tiJn ièr? ct5 : !
llfnu'A(Y't ir;':er ¡rd :

@

 -23-t

late oi

c

S

lOlv,\ (:tIY
v Ihttt tISt¡lt:t

)

lusion Time-Out Log
Studen

6rade:

l¡¡e of tncrdent:

\ - ä)'

5

t

t5

iime of tncrdenr!

I

ïeam members involved:
',Vhat was happening immediatelV prior to the stud ent's problem
behavio r ( antecedent):
, ght¡argument wrrn

_

,.¿

!

-

'

_

pÉer

jtuc,ent w¡ts grven ¡ task
{whðt kind of

_

tut'¿ent w¿t oenred oreferred ¡cllvltv or

i¡udent was ðsKed to wal!

r(em . {-

itucent

ta¡k?

I

,,roant was expected to transltion

T:acher was ¿nendrng to cthers

-

lvð5 prompted ro use specrflc feolðcemeñr behavror
lwnich

one?

I

tcudent was rotd to move ro another locauon
ituclent w¡s gtven one-on-onÊ enenïon ldescnbe:

,-ìÜ.er

-

3

¡rior to restralnt or seclusion,
ìoom cleir lremove

\-

)

iet

_

hmrts (rf,

please descrtbe lhe de-escalation strategies
thatwere attempred by staff:.

auorencef

thenl

X

5ct ð ttmef

f,irecl to cool down

area

_

Ðffered chorces ío¡ cool down

,gñonnt (not provlding
anenïon for e¡calated behðvtorf

,:rzrnptrng use of reclacement

behavror

_

tirstlthen

r)t

5tudent non-dggressive behavior prior to restrarnt or seclusion:
C-

Su¡.q*s\.

Student oqgresstve

r pnor to restraint or seclusiont

c\
Student aqgressive behavlor durine restraint or seclusion:

c\ \\ac\c¿.
-ime

out:

è

3egrnnrng

S¡sc^¡ifr
¡¡¡¡¿¡

\ ',S8

-\r^nÇOlr)
inding trme:

2 : f ..{

rr.åvarlable, need ¡dmrni¡trðtor agproval ldocument ttme/approval):

Physical restraint

@

¡lo

{,.,

r

È
' lf duratlon erceetr

chitdren's conrror

llo Concernt

positron

-{.,Aettnntng Ìtme:

r

SO

minutes

- nred oárent aoprovrl, rf prrenr

conrror pos¡tion

ìfB.

Ênding trrne:

:ranrpoß Posrtrcn

-\js8

Concerns, descnbe:

3¡gñ¿rure:

rr

i"e

 be other

ribe
u
L

-

I
I
I

let to othef studþnts' storf ¡nd/or property damaqe:

what took place aiter time out was complete:

Student

.

lnluf

lrro"nt

resrsred rhe

rstuf ned ro wor[

- :¡¡tf

met iniormallv.as

; tatf

'.vril meer

3

about the'oehavrof
Student and staff engaged rn a pfrv¡te conversatron

rask

student returned to work wrrh

@

space
Sludent transrtloned to qulet åctlvlw ln a prlvale work

envronment

rhe

)

student returned to gen. ¿d' tettlng

group

(?am to revlew curlent lnteruentlon slrðtegles

-

dalei
icrmallv ar a tgðm to revlew tðA/AlP llvleetlng

time;-)

ordingtothecurrentFBA,whatisthehYpothesizedfunctionofthisbehavior?
:ne cuffent

*

FðA iroes not ador€ss thls pantcular oehavlor

(meetlnt musttake place' ¡ee ðoove to documentl

_.íhrsEenaviortsmatntarnedbyaccesgtoadultanenllonThi¡behavlortsmatntatnecjbyaccesstopeerattentlon

îhis

-V
-*

Eenavtor

ti matntarned

bV escape

from social interaction

tasks or actlvlllt¡
a,'r,, þenavror ti matntatned bv eScape from un-pteierred
marntaln€d bv accesS to preicrred

ltem!/actlvltlet

ihlS

cenavlor

-

î5tt

retnf orcement
oehavror ts malntatned ov ¡utomatlç

oes

lhis

hvpothesrs match the ABC of this incident?

15

@

^,¿r

)

_¿à'¿,,ÐUf¡nt€Ív€ntlonwå5ðoproDl at!andlnStructlonðl/¡nterventlonslrðteEleSwrllstaythes¿me
rÈS,howevef our rntefventlon mðv nSve relniorced

-

¡¡o.

otan'
the negattve benavtor' rhe team wlll revlew the respon¡e

fo¡ 5
matçh thrs rnc¡dent. Agc ,l,rt,r wrtl be ccllected
¡.fle nvoornesrÍ t,o¿¡ óot sÉem ro

ineouled lolea¡e document tlme

d¡v: and a meetlng to

?evr€w the FBA

wtll be

and date asovel

,Vhåt is the desired replacement behavior?

low rnanv

IEP?
provided for teaching replðcement behavior on thls student's
rninutes oi specialîy designed instruction are

,'l¡ñutf;5 anO gelvlce Orovtder

¡he le¡m wrll

I ¡rent/Guardian
:ioort

2o

rm.\¡¡tJ

time to te3ch this reolacement behavlof
need to fneet (o Ciscuss aoding mlnutes of servrce

\¡ethod of contactl

comcleted
murt 5e portm¡rhed to lh! parenV{uårdlånl
lolcler ard
:end copler of report toi Prrent, Studant Cvmuta¡tve

@

 fatc of Documenr¿ronr

c

l()!V¿\

7' L1 '

t5

cl'tY

Y  l.trrt ¡Islt3t..l'

lncident Report O

)
5tudent

3uílding:

l¡te of lnç¡dent:

iime of lncldent:

luslon Tl me-Out log
6rade

-

?:rÐ

curtt¡on of

tnctdens

2P, ru^sfßS

feam members involved
',Vhat was happening im

_'

ately prior to the student, s problem behavior (antecedent):

ghtTargument '¡lttn oeeÍ

_

jtudent w¡r grven a ta5k (what kind
of task?

-llw¿e¡r wðs oenred oreferred ðcnvtty or rrem
'6oon
_ !rudent wðt asxed to watt
-{rcuftent
l/)tuoent

was rotd

5tudeil

!va5 expecled

to rranstuon

-(r"rnrrwas

anendrng to

wa¡ -prompted to use specúlc reolacem€nt behavior
lwntch one?

!o rflove !o another locauon

wà! gtvrn one-on-one ¡ttentron tdBscnbe;

,-:it ef

Prior to restrarnt or seclusion, please describe the de-escalation strategies
that were attempted by staff:.

^Õ

Ua--.ioomcle¡rlremoveauorencel
)

lrm¡ts lrf,

X

thenl

leta

lrmer

)irectrocoor downare¡

-2S

offeredchorcesiorcoor down

'gnorrng (not providlng anenrron for escatatcd behðvlor)

-

_ ,:r?rnptrng use of r¡olacement behavror r)the
-:et
jtudent non'oggressive behavior prior to restraint or
seclusion:

5tudent oo

behavior

to restraint or

r¡)rtltr,.n

-

I

clusion:

Student aqjressive behavror duri¡e restraint or seclusion:

iime out:

3sgtnnrng rtme

,4

øy'

Endingr,mer

1åL

'

lf duratron exceeot 50

minuter,

.¡¡avalla ble, ¡eed ãdmrnirtrator aoproval (document trme/approval)

Physical

/?s

restraint:

-;'lo

@,

'¡ias used

-

children's conrrcl

)to

Concern¡

pos¡tron

*4ur^control

Begrnntng trme:
Concerns, descnbe:

4:a

neect

o¡rent aoproval, rf p¿rent ls

posrrion

inding rrrne;

2(,unyonPosrtrcn

î,04''"

 studþn15, stsrf ond/or

be other rnlurles lo other

ribe what took

. -ituden! restored ¡he

(rrro"n,

\

¡íter time oui

place

*t'

task

I

o

complete:

envtronrflent

returned ro work

I

propeny damage:

Student lranSltloned to gulet aÍlvltY ln ð pfivðte work rpace

{rruo"nt

and staff engaged ln a pnvðte conversatlon about the behavror

Þ

-itudentrelurned!owort(wrrhrhegroup-Stuclentreturnedtogen,ed'reïtng

- i¡¡ff
3

met informally as

talf

,.v¡¡l

¡ t33m to revlew current lnteilentlon strategles

(tv1e€tlng date/time:-)
mert l¡rmarlv as a t3am to revrew FðA/8lP

ording to tne current

Ee¡avtor rt marntarned,bY açce55 to adult

:hi5

I

b¡navror

15

_

Thls behavlol ls matntatiied by access to Þeer altenllcn

bv escape

lrom un'preierred tasl(s or ¡tcrlvltle¡

ceFðvlol li marntarneó bv access to oreierred ttems/acttvltte¡

Thls sehi¡vlof lt ñðln¡ð¡ned

-les lhis

åttÊntlon

docuíientl

marntalned by escape from sociål lntelastion

t,.r,, benavror r¡ marntatned

;hls

V'

what is the hypothesized function of this behavior?

(meetlng muS! take place' See aoove tO
l.AA doe¡ not address thls Fartlcular çChavtOr

:ne cuffenl

_'ihrs

FBA,

ÞY

¡trlornðtlc retnforcement

ü

hvpothesrs match the ABC of this incident?

,;

""..1ur

strategles wrll stay !he same
Intervenaon was ð'proprrate ¡nd tnsrructtonaUlnteNentlgn

)

olan'
.r,z5,however our rn[efventron mav have ranforced th€ negailve benavtor, rh'e leam wlll revlew the response

rro. t;:e nyootnesri

,Joes not seem

ãnd a ñeetln8 to 'evrãw ¡ñe
to matsh thrs rnc¡dent. Agc.J¡t! wrrl be cctlecteo fo¡ 5 d¡vs

FBA

w¡¡l be

:iìe6uled tole¿ie oocument llme and oate aoove)

Vhat is the desired replacement behavior?

1A Qoc o\
acementbehavloronlhlsstudent'slEP?

low rnanV minutes oi spe
.'lrôUt€5 And Serulce OrOvrder

æ

ihe

of servrce t¡me to te3ch thi3 reolacemÊ-il
term w¡ll need ro rneet to clgcu5s aoding mrnutes

l:rent/G uardian Contactl Ðate:
::ooil

com

o"W.

gc-V*rÞ

',tethod of contact:
.rdmrnrrtratof SlSnature:
mur! b€ poÉtrn¡ll(rd lo th! p¿rerttlÈu¿rdi¡nl¡l

¡nd Educ¡rron
:¿nd toolÊl of rrport to; P¡r?nl, Sluden( €um.ul¿¡r'¿e tolder

c
)

 r)¡te of Docurnenr¡tlont

L

tow\ (llTY

ü

ort Document and Secluslon Tlme-O

t

Stude

Grade:

Date of lncldent:

Tlme of lncldent:

Team

members involved:

What

was happenlng lmmedfately p

rto

_

flght/argument with peer

5tudent wa¡ denled preferrÊd ¡ctlvity or
Student

w¡! arked to w¡lt

0uratlon of lncident:

e studenf s problem

Studenl wai Blven e tosk lwhat kind of

ltem

tosk?

Student was expected to

I

transltlon

-

.:

was ettendlng to

others

-leacher

Student was prompted to use speclflc replacement behavlor (which one?

Student was told to move to another locatlon

_

Student w¿s glven one.on-one attentlon

Othe

Prior to restraint or seclus¡on,

,{F

Roorn clear (remove

please describe the de-escalation strategles that were attempted by staff:

audiencel

Set a

Dlrect to cool down

area

0ffered choices for cool down

lgnortng (not provldlng attentlon for e¡calated behavlor)

set limlts (lf, then)

First/then

-

promptlng use of replacement
5

tlmer

behav¡or

Other:

ìudent non-sggresslve behavlor príor to restraint or

seclusf on:

(
Student

S

to restra

tor

n:

c

nt or seclusíon:

tudent aggressive behavior

Tirne
u

I

b

out: Eeginning o^"tcÌ i 13

ena,nsú^",LZL.

rf durauon exceeds so minutes

-

need parent approvat,

nava ilable. need admlnistrator approval (document time/approvall

Physical

restraínt:

_

fro

Chlldren's Control

Yes

-

3,tglrìning

I
tron, rf ohyslcrl rtstr;ìrn(

þ:varu.r

u¡su¡:cJ:

t:oncernî
-Ã.
^¿ 'lo

Poiltlon _

--

t¡me;_

rirltìt€lnS, rJ'lSCrtbe:

T:am Control Position

lnding rirne:

,/
/_f

rf

parenr is

,ft' 'lZ -'1,' i3
ransgort Posltlon

 DeJcnbe 'Jtl"sr

rnluries to ,:ther

ltudentr, ¡t¡tf ¡nd/or property ,J¡magr:

Describe lvhat took place ðfter tlme out v/ãs completel
l¡'

\ '"'

¿h,\Tt :

;,r¡"nr

rrstored tha

;(Ldênt r:turned

1o rvrrrk

ir¡ff me.níormaily
Staff

'.vrrl

envtronmenr

Jtudent tr¡ngtloned lo qulet ¡crvtty rn r pnv¡tte work rp¡ce

t'rsk

as a ream

Studcnt rnd rtarf engaged rn .r prrvate convers¡non,lbour
the benåvror

to revrew current intervenilon strat€gret

meet formarly as a team ro revrew FBA/Brp (rviettng

date/ilrne:_

 

Other

Acco.rdlng to the current

FBA,

what

fs

the hypothesfzed funcilon of thls behavtor?

the currant FBA does not ðddresS lhls partlcular behavlor (meeting
must täkG plecr, see above to documentf

fhls behavlor

rs

mðlntalnld by access to adult

attentlon

Thlr beh¡vtor l5 m¡lntalned by access to peer attêntlon

fhis behavror ir marntahed by escape from ¡ocrar inttracilon

---

V

^

rhis bêh¡vror is marnt¡rned by escape from un.preferred
t¡sks or ¡ctrvrties

lhl¡

behavror ¡s m¿rnt¡rn€d by acccrs to preferred items/lctrvrtres

Thlr behavlor

15

tnatntalned by automatlc relnforcement

Does thls hypothesls match the ABC of thls ìncident?

' Ð+

Yes, our lntervention w¡s åpproprlate ðnd lnstructlondl/lntervenrion
rtrategtes

will stay the råm€

'/e¡' however our interv€nti9n may havc relnforced
the negative behåvior. fhe team wlll review the re¡ponse plan.
¡¡o' the hypothetlt doel not se€m to match thls Incldent. AEc
dðt¡ wlll be collected for
scheduled lple¿se dscument tlme ðnd dote above)

5 doys ðnd a rneetlng

to rev¡ew the FgA rvlll be

Wha t is the deslred replacement behavíor?

How many minutes of specially desígned instructlo n are provided for
teaching replacement behavioron this student,s lEp?
It¡llnutes ¡nd ¡en¿ice provider
fhe te¡m w¡il need to meet to discuss addlng minut$
of ¡en¡tce time to teach thls replacement behavlor

Parent/Guardian Con

Method of contact:

Feport completed by:

Admtnlstrator slgneture:
A

wr¡¡¿¡ g6py

0 rÉport must

Sdnd Copler

)

br por!m¡rled lo the p¿renr/guardian(rl

,,vrthrn

of report toi pür¡nt, 5tudent üurnulative folder ¡nd Educ¡¡lon
Servtcg¡ 6¡¡s¿¡

 -l

c

Èr
9l

lncident
5luden

Re port

Jte ot Documentðtton:t

l()1tr\ (.'l'ly
{ ilr {rt t[\l [ß.1

Docurnent

on Time-Out Log

Surlding:
Grade:

: ltE ot inctdenï -

iinr¿ sf :¡ç¡¿ç¡¡.

-'ur¡tlon of tnc:d€nt:

ïeam members

.,gnt/ar'umenr,,vrrh

e studen

cser

\{_

_

lvat Jiksd ¡o.,vðrt

em

vior

s,ucan, war grven I task
(rvnat trnd ol

Itudent".v¡¡ cen¡ed oteier¡ed
actrvr!y or rtem

jtudent

f

lnvohred:

',Vhat,.vas haopenrng im

_

,v --'l

J

t¡¡ k?

-t

,-¡

çú,

ûUr-ïlr

!i

or'1r

. 5t[,¡,.{ent tvar el(oected lo tt¡ns¡t¡on

I'e¡cher !vðt tttÊnolng
to others
i¡u,Jent wa5 oromotfo
to use tpectrlc teplacement
behe vlor lwh¡ch one?

_

-:tudent rv¿¡ told to move to ¡nother
loc¡tlon
jtu den!

w¿¡r gtven

one.on-one ¡ttentton I
Jerqflbe:

!)ther;'
-

Prior to restrarnt or secrusion,
prease descr¡be
the de-escaration

I

:loom cle¡r lremove
audicncel

iet lir¡rts lrf, tl.enl

¿

t 

,.:romptrng use of replacement

,/

.)e t a ltmer
,gnonng

behavlor

st rategies that

r, rect ¡o cool down

lvere artempted by
staff:

are¡

(not provtding ¿ttentton
fo¡ escalated b ehavrorf

-

Student non-oggresslve behavior
pr¡or to restraint or
seclusion:

:¡

,)
Studen t cggressive
!tudent

* -'

"i

il*

r .'¡i-.. '.
ìegrrn..¡ ¡1¡3 itr'.u'L.,
i' lvì¡r tol¡, -3e! ;d1,n:si,3lcr
3 3J¡c rål

Jd:¿

ind¡':l f,re: ,, l, .. ,
.¡,r:nt

..irn

?/ ea crcva

lf:

._- ,,,

J,;r¡¡.s1 irc3eds S:
n,nr..i:rs _ i€,ed ,ar?-l
!cortv¿I, ,f :areni rj

ìJ

_

:" J¡en'¡ l:r:'ci :i!,¡.¡1
-

:

"

r.rirãint or seclusíon:

-"¡g OUt:

r:slratnt

¡kfr1"'

behavior orior to restraint
or seclusion

aggressive behavior
durine

âi.',7sical

Fir:t/then

Other:

Lir''arì ;:,-,;s.:¿l .:fsÌ.¡ -:
.,tli -:: j

''

'

'l': r-:':cr-¡

.

..¡!m

fcrÌ::l âo5::n

¡r::,)f! r'):.::n

 l¿icrtþ€ o!n'tf

'r'tul'¿9

to c(her

ltudentr' '':¡lf

¡11'J/ol procef lv o¡mr'¡g€i

tlrne out

took place 3fter
D¿scrlbe whðt

l iudent

r?5tore6 tne 'ilnvrronn:en

;tudent

r¿lurned t3'JJorì(

-¿'StuJent

'

!1
i lu ¡e nt 'eiurned "vor( "vr(n

prrvJte '¡'ork toace
-,.^
to out¿r 3ct;vrlY rn a
tr¡nsrironed

s

''t{"'o"n'¡ndrt¡rleFgagedrn¡¡rwateconversðt'onaboutthettn¡uiot

iSlx
:ne

wðscomplete:

:o' !¿ttln
ltuoenl lålufneÚ to ãln'

gfouo

g

!tail"v'rt r-::t i:rr¡¡trY
:

tner

¡

ã5

:33m !ã :etJr:'¡i ¡3A13lP

l!\re¡ll¡g

öate/ll.ne:

'

funcrion of thiS behavror?
is the hvpothesi¿ed
FBA'
current
the
to
"vhat
place, see aco.te lo doculen!l

\cco rilng

¡3tr¿
benevlol lrfregtìng mu 5¡
Í34 'Jcer ncr aódrets Ìhr! cañlcul¡r
ç9¡r:nt
-,-g

sdult
-hrs cÈh¡vlol tt mttn!¡tned oY accelt to

cÈ¡¡vlol

'
-lrlt

'cÈnavlof' lt- l'¡ðrnt¡rned

'

_# '
t

"

íF'l cenavrol

Peer åt!9ntlon
rt m¡rn[atned bv ¡ccei5 to

irom soctal rnÌel3ctlon
m¡¡ntôlned rv e5c¡pe

;hif

r3

ltlanllon

¡ask¡ or ¡ctlvrtlei
cv elc¡Ée itom un'preferred

bY ðcge5s to or¿f erred:tem!/¿lctlvrtlet
bÈnavrol l5 rfr¡rnt¡ln€O

-:hlf
match the
Does this hYpothesls

ABC of this incident?
3'tme
str ategret lvril slðv the

¡nd inttructlon¡utnterventton
'l¿5, oul rntervenllon '¡'/¿¡t appropltðte

\-/

fhe
[h€ ne8¿tlve oehavlo r.
m¡Y have rernforced
'/e5, howevel oul lntervenrlon

te¡m

.vttt

glan
revtew the r€:ponse

o

ÀEC d¡ta rvrll be collectedtor5d¡vsrndlmeeltngioreulew¡heFEArvrllbe
to m¡rch thtr rnc¡dent'

not reem
)to, lhe hvpoth esl¡ doe¡
and date ¡bove)
ttme
nt
{Please oocume

,cneouled

',r/hat ts the

'i
'I

on this s tudent's
replacement behavior
reachtng
for
provided
structìpn are

l{ow rnany
gerVtCe plO'/'def
.'lrr'rl!ê5 and

,

g minules oi
-*e 'e¡¡¡ ,y¡il 1ê€J :o r.nPe!:o llscus9 ¡ddtn

: l rent/ Guaroian conr'act: J¡:3:

, '

genrt¿e rime

.' I

'

behavtor
to te¡ch th¡s reorãcernent

cf ton''¡ct;

.'"lÈlhoo

;.J1l1'nr!'.rltCf

! 3nåtule'

1?c:lr ::-:''!!d
c¡ltlr ¡iled
L!i :Ìe1 ::cï ¿l ihe'giof: f'J3t:e

IEF

tâ Ì."?

Olr¿lt'l!¡rdl¡nlJl

)1rent' 5:L:err C'rurJ('v¡
:^d c:É,e! ¡f tl:ori tcl

it

Àrf

llñ t"?e rj¡rts

ier ¡nc llurat'¡n Ser" c¿t

Of

l'e

rc ãeal'

:l¡ter

{þ

 f at€ of oocumentatron,

c

I - Z'{ - I S

tolv ct'tY
s ll¡lll¡ ttrtttta:f

lncldent Report Docurnent an d Secluslon Time-Out
Log

)
Sludent:

Grade:

l¡¡e of tngdent:

iime of

lncrdent: t I

(>

:

I

qur¿tlon of lnclden¡:

Ch."..O C.LY\IIhJF-( 20
Team members involved:

{nr-<*

',Vhat was happening immediately prior to the studenf problem
s
behavior (antecedent):
ght/argument wrln ocÊr

,X;,ro.n,

-'

:rudent wa¡ oenred oreferred

-

!tudent wa¡ asxed !o wa¡t

-_
_

itudent

was told

:tudent

v.rr'.

¡l,:¡ \r¿S

,¡¡.r ån.-¡- o.{ +r-<.

¿crrvitV

O.+*

t5tÀ+.-

c-\

è")

was grven a raik (wh¡t kinct of tark?

oiìrem

Stud€nt rvðs expecred

to

translrron

Ã

ï€acher wðs ¡nendtng to cthers

-

Studcnt !va3 prompted to us! specrflc replacement
beh¡v¡or lwnich on€?

to move to änother locauon

wðs gtven one-on-one ãttentton tdercnbe:

,-!tl.e r:

o

Prior

\)-

to

restrarnt or seclusion, please describe the de-escalation strategies
that were anempted by staff:.

ìoom cle¡r (remove

auolencel

:el Imrts (rf, thenl

_

J

.lrrrnptrng use of reolacemen¡

ict

å

rrmer

-X
rgnorrng (not providing

behavlor

)irect

þ cool down are¡ Xon.r"d

arrrnrron for escalated behavtorl

r)ther:

cho¡ce¡ for cool down

rirrtlthen

-

iludenr non'oggressive behavior prior to restrarnt

or seclusion:

\o
I
3tu

nt

fsc¡(

rC,<.

I

\^.{â^)
5

tudent aggressive behavlor durinE restraint or seclusion:

ct d¡tsC:

Time

out:

ñe¡¡!- 5
3agrnnrng nme: \ \l

\r^S-¡-

C

\ \:'Þê ' rf dur¡tron exceeos 5o minu tet - need oerent aoproval,

3ô

9rding trme:
ira./ðtla ble, n:ed :dmrnistrator aoËroval (oocument ttme/ðpprovðll

Physical

@

Âto K ,.,

restraint;

-

chitdren,i contrcl

-

posrtlon &rrr^conrrol posrtion
)(

ãegtnnrng

t,me. ,

I

(

,'3()

inding

rranlpon pcsrtrcn

trme: t \:3ô

Ccncerns, descnbe:
5:gnå

turei

S\^4

:i^e:

)

 be other

rnluf le5

damagel
to other studþnt3' storf ¡nd/or properW

ribe what took

place aÍter time

o'i *"

o

complete:

î

studentreStorldrheenvlfonrnlntStudenttranlltlonedtoquletacrlvrtytnapflvateworl(space
- ;(uoent

returned to worl

the bchavror
and 5tåff engåged ln a prtvate conversatlon about

task

Þ

-J4tuotnt

=r,ro.n.rerurnedßoworkwrththegroup-studentleturnedroSen'ed'setttng
lnterventlon strategles
met informallv ð3 ¡ team to revrÊw currÊnt

- i¡¡tf

revlew iðA/ðlP lNleenng
Statf wril rneet f¡rmallv as a teðm to

date/rlmel-)

!r:

ording to the cuirent

FBA,

what

iS

the hypothesized function of th¡s behavior?

-:necuflentFAAdoesnotadoresstht¡part¡cul¡rcehavtor(meetlntmusltakeplacc'¡eQaoovetodocumentl

_.íhrsbenaviolt¡matntalnedbyaccesstoadultattent¡onThisbehavrorlsmalntalnedbyaccesstope€fatlentlon

ïhis

)!:''rs

Þenavtor

matntâtned bY esc¡pe from soc¡al interactlon

un'preferled ta5k! or acllvltles
benavtor t¡ marnlarned by escðpe from

;hlÉ cenavlol

-

rs

ls rnarntalned bV acçess to oreferred

ttem¡/actlvttle¡

ihrs

rernforcement
!ehevrol tf matntatned ov ¡trtomðtlc

-oes lhis

hvpothesls match the ABC of this incident?

v

''

",Ður

o

slr¡teßle3 wrll stav the same
¡ntervenlon wâs aopropllate ðnd tngtructtonauinterventlon

the neEatlve ben¿vttf
'/ es, howevel our lnteruentlon mav have retniorced

-a,o,r.renvootnesrrdoe¡notreemtomatchthrsrncrdent.
aoove)
:;reouled loleð5e oocument tlme and dðte

Vhat is the desired replacement behavior?

{ow manY minutes of sPe

r.

)

rhe team wtll revtew the response otan'

ABc,JJtð'.!rll becallecteolor5d¡vsand¡meetlngtorevrew(hÊFBAwlll

be

tô.-\cr.- a b".<s--Ltr

behavtor on thls student's IEP?
instruction are Provl ded for teaching replacement

i'.'lrnuti5 and genrlçe orovrder

Íhetålmwtllneedtome€tlodiscus5addinBmlnute5ofsen¡rcetimetoteachthisreolacem¡-nlr:åHP

¡rent/G uarc ian Con
¡a90rt

\lethocl of contact:

g¡.e/r-q\k\

a¡t.   \

c.^SS-

ntrtrÐlor Slgnalure;
bc postmarkld to ¡hc parentlEu¡rdian(:l

tolder ard Educa¡ron Serv¡ces Cenler
l¿nd ccole¡ of reporl toi Psrent, Studen( Cumul¡Uve

û

I

 Date of Oocumentationr

?;

t

l()!v^ (:¡'tY
v llrhx IIrtßh-'r

lncldent Report Document and Secluslon Tlme-Out Log

Studen

t:

Building:

Dðte ot tncident:

Grade:
t

Ilme of lncldenti

Duratlon of lncldent:

Team rremberi ihvöþed:

What was happening immediately prior to the student's oroblem behavior (antecedent)
fight/argument lvtth

pee.

X

stuorn, *ås grven

it€m

-

Student

-

student wai asked to walt

-_
_

Student was told to movr to another
- location

was denled preferred ðctlvity or

a task

(whðr kind of task?

Student wa¡ expected to

transttion

___

Teacher wðs attend¡ng to others

-

Student was prompted to use speclflc replacement behavior (whlch one?

Studentwas Blven one-on-one attenilon

(descrtbe:_

I

o
Prior

to

restraint or seclusion, please des.cribe the de-escalation strategies that were attempted by staff:

 .-Roomclear(removeaudlencel 5etatimer
-)C
_

5et limits

(rr, then)

Directtocool downarea

lgnoring (not providlnB attenilon for escalated behaviorl

ÅL

prompttng use of replacement behavior

"-<<1

offeredcholcesforcool down

-)(
_

.L- n--

First/then

tt ts¿p.þ

l,l

Student non-oggressiye behavior prior to restraint or secluslon:

Student aggress¡ve behavior orior to restraint or seclusion:
t

I

Student aggresslve behavior durine restralnt or seclusion:

\
Time

out: geginnhgtime:2i05

tndlngtime:

unavailable,needadmtnistratorapproval documentttme/approval} 
"-:tL

Physical

restraint:

_¡¡o

I

c

'rf duration.r.."¿rs0åinute¡-needparentapproval,rf

[hildren's control Position

)Ç.r.t
-

ream control

- 210{

Begtnning time:

posiüon

Ending t¡mer

Transport poiition

2f\<

s,.l,,t,on.ifphyslca re5traintrualused:X¡loConcerns-Concerns,describe:
Signature;

parentts

Time;

 rtaff ond/or property damage:
Dèscnbe o t her rnlufres to other rrudents'

Describe what took
d ent

place after time out was complete:

re3tored the

Stu

_

Student

_

Stu dent returned to work w¡th tÞe'Eroup
-

task

returned to work

student and staff engaged in â privatc conversation about the behãvlor

-

Student returned tP Ben' cd'

settlng

$i
'u'-À

.

_Staffr.,,*o,.,',.,,rrr;;r;,rÏ,.*'.r,,1r,-.rven.on,,,.:i1..""
5

w¡ll meet formally a5 a team to revtew FBA/8 P (Meetlng

taff

According to the current
rhe cunjnt

Does

r,
{

.l

. ,,':

date/tlme:-l

-lt J

Other:

,Lf

o

Student ¡ransltioned to qulÊt activrty ln a pr¡vðte work space

envrronment

_

FBA,

what is the hypothesized function of this behavior?

place, see aboye to documentl
rg1'ddechof åddress.thlq pei¡rc¡rlar behavlor lmeeting must take

attentlon

lhis

behavlor L mainteined by access to adult

This

behavior i5 malntained bV esc¡pe from social lnteract¡on

Thls behavior is maintalned by access

to peer attention

¡ctlvities
h ls behavior ls maintalned bV e¡cape from un'preferred tasks or

f hls

behavlor ts mð¡ntâtned by access to preferred items/activltlel

fh¡s

behðv¡or is mðlntained bY automatic relnforcement

this

hypothesis match the ABC of this incident?

yer,

wrll stay the same
our interven¡on w¡s ðpproprlate and instructional/lntervention strate8let

ves,

the team will revlew the response plan'
however our ¡ntervention may have rernforced the negative behavior.

.Noi the'hypbthess

-scheduled (please

doäs hot seem

to match'ihi¡,incjdent, ABcdâta w\ll'be collected for

5 daYs and a meetlnB

û
to re'view the

FBA

will be

document tlme and date abovef

What is the desired replacement behavior?
tedching replacement behavior on this student's IEP?
How many minutes of specially designed ¡nstruction are provided for
Minutes and

f

servtce Provrder

this rePlacement behavior
he team wrll need to meet to discuss adding minutes of service tlme tO te¡Ch

parent/Guardian Contact;
Report comPleted

oate:

s/*/6-rime:

tjlf

Methodof contact:
Adririnistrator

bV:

¡ wntten

copy of rhe repolt

ñutt

be po¡tmarked !o

si

gnätu

th! p¡rent/Suardlan(s) within three daYs of the incldent'

:ÈndcopierofreporltolPafent,studentcumul¡tlveFoldef¿ndEduc¡ttonSefvicÊ3center

@

 DJte of Oocurnentotion:

lO\V¡\ (llTY
\a

Ð

' rx,l.

tttitxtf:f

Document and Secluslon Tlme-Out

Stud

ent:

Grade:

Date ofl

fìme of lncldent:

Duratlon of lncldent:

Tea rn members invo

What

lately príor to

was happening i
flght/¡rgument wlth

peer

_

Sudent was glven a tssk (whot klnd of task?

ltem

student we¡ denled preferred actlvlty or
student wal asked to
Student wrs told

_

walt

s problem be

Student was expectcd to

trans¡tlon

_

Teacher was attendlng to others

-

Student wa5 prompted to use speciflc replacement behavlor (whlch one?

to move to another
- locatlon

Student war tiven one-on.one ¡ttentlon

(describe:

-

l

Othert

Príor to restraint or seclusion,

please describe the de-escalatlon strategíes that were attempted by staff:

,Ð --r- Room clear (remove audlencet
(if,thenf
É{.tfimrts
/
promptlng use of replacement behavior

Set a

timer

Dlfect to cool down ¡rea

Offered cholces for cool down

lgnoring (not provlding attentlon for escalated behavior)

First/then

Othe

5tud,ent non-aggressiye behavior prior to restraint or seclusíon:

L
Student oggresslve

to restrai

Student oggress¡ve behavior

dr.¿rinq

or seclusion:

restraint or seclusion:

(_.

a

Tf

me

out:

BÊginning

Ending time:

-

ß 5q,

¡

lf curation exceeds s0 minutes - reed parent rpproval,

rf

parent is

unavailable,needadminl5tratorapproval(documenttlme/approval)i

r
Physical

llo

festraint:

'-h.

,fl

v

Yes

-

-

Êvrl.r.lfion, 'f ohy;rcal 'estra.inr,,./as urÈd:

Children'¡ Control

_

ilo Collc:rnt

B.rgtnning

_

conrrol posiflon

Postt¡on

ùr)ncer¡,1,

-Team
trr¡e:_

¿

'i

--

./.¿

^'ì

.'
-'
.' \.Tr¿nsoort Posltlon

ãn,Jing trrne:

,J-e5rf rbÈ.

j"'ì- ¡i:

t

,t !

t'-l

 .t)escilbÈ

0rher rnlunes to cther ttudentt,

rt¡tf Jnd/or property,J¡rn0ge:

Describe rvhat took place after tlme out was complete:
'

Þ

;t'rdent rÊstored the

envtronmenr

i(Ldant returned to rvork tork

Z

i¡udent ¡lturned ¡o work r.vtth the

iraff

mer iniormallv

es

¡

itudent trensitloned to qulÊt Jctlrlty tn ¡ pnvirte work tpâce
sturlcnt :nd rtarf enga¡ed in a prrvote con,rersðtron ,rbour rhê benavrrrr

group

teem to raview

5tudent ¡eturned to gen. ed. senlng

curent rnteryentlon stretegles

5taff wrrl mert formarly ¡s a team to revlew FEA/Brp (Meetlng

date/tlme:_t

Other

According to the current

FBA, what is the hypotheslzed functlon of this behavior?

the current fBA doe¡ not addrett thl3 particular behavlor (meetlng must take place, sec ¿bovê to documentl

lhi¡

bchavlor l¡ melntalned by accesr to adult

arentlon

Thlr behavior l¡ m¡lntirned by access to peer enentlon

lhls behavlor i¡ matntalncd by e¡cape from soclalinter¡ctlon

-

fhis behavtor

rs

malntarned by escape from un.preferred tashs or actlvttler

Thls behavlor lr matntalned by occess to preferred ltems/¡çtlvltlet
This behavlor h malntalned by outomatlc relnforcement

Ð

ï llïdififi,îr;'": #;ffi

::",:ï"

:::,::;î:,.

resp. n,e p an

No, the hypothesis doe¡ not re€m to match thlg Incldent. ABC d¡ta will be collected for 5 rlayr and a meeting to revrew the FBA will be

scheduled (please document time and date above)

ry'/hat is the deslred replacement behavior?

How many m¡nutes of specially designed instructi on are p rovlded for teachlng replacernent behavíor on this student,s lEp?
lvllnutes and

ser,¿ice

provider

_

rhe t€¡m wtll need to meet to rJi¡cuss addlng mlnuteS of :ervice tlme lo teach thil replacernent behavlor

Parent/Gu¿rdian Contact: oate
Report completed

by; .,
A

'/ cl'lt
++/

Method of contact;

Admini¡trator rignature:

lyflttên coov of lha rûport rnus¡ be posrrn¿rked lo the p¡rent/luaadlån(51 wrth¡n t
Send coplet of

)

fime:

repor! to: p',¡rent, Srudent Curnulattve toldet;nd Edusation Servlcêr C€ntef