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Behavior Intervention Plan
Initial Plan ____
Plan Revision ____
Student Name or ID:
___________________________________________
DOB:
____________________
Plan Date:
_______________
Next Proposed Review Date: ______________________
Developed by: (identify those involved in the development of the plan)
Name
Position
Name
Position
______________________ ______________________
______________________ ______________________
______________________ ______________________
______________________ ______________________
______________________ ______________________
______________________ ______________________
______________________ ______________________
______________________ ______________________
Positive behavior supports and strategies in place, which will be maintained:
Document practices, strategies, supports and interventions implemented at each level as appropriate:
UNIVERSAL:_____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
TARGETED:______________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
INTENSIVE:______________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Resources Required:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________