Behavior Intervention Plan Page 4
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Student Name or ID:
_________________________________________
DOB:
________________
Plan Date:
__________________
Target Behavior(s)
Replacement Behavior(s)
Intervention Strategies
Person(s) Responsible
Review Dates Timelines
Progress/Evaluation
(Desired Outcome)
1. _________________
1. ___________________
Antecedent Strategies
1. __________________
1. _________________________
1. ___________________
____________________
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2. _________________
2. ____________________
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2. __________________
2. ________________________
2. ___________________
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Instructional Strategies
_____________________
___________________________
______________________
3. _________________
3. ____________________
________________________
3. __________________
3. _________________________
3. ___________________
____________________
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4. _________________
4. ____________________
4. __________________
4. _________________________
4. ___________________
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Consequence Strategies
_____________________
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______________________
5. _________________
5. ____________________
________________________
5. __________________
5. ________________________
5. ___________________
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Indicate date of PPT during which this plan was discussed, agreed upon and became a formal addition to the student’s IEP:
________
Additional information:
_____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
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