PTRYC Prevent Form Sample.pdf

PTR-YC Functional Behavioral Assessment Checklist: Prevent

Challenging behavior: ____

Person responding: ____

Child: ____

1. Are there times of the day when challenging behavior is most likely to occur? If yes, what are they?
Morning
Afternoon	Before meals
Evening		During meals
Naptime		After meals		Preparing meals
Other:

2. Are there times of the day when challenging behavior is least likely to occur? If yes, what are they?
Morning
Afternoon	Before meals
Evening		During meals
Naptime		After meals		Preparing meals
Other:

3. Are there specific activities when challenging behavior is very likely to occur? If yes, what are they?
Arrival
Dismissal
Large-group times
Small-group times	Naptime
Toileting/diapering
Special event (specify)		Peer interactions
Centers/free play
Meals		Snack
Transitions (specify)
Other:

4. Are there specific activities when challenging behavior is least likely to occur? What are they?
Arrival
Dismissal
Large-group times
Small-group times	Naptime
Toileting/diapering
Special event (specify)		Peer interactions
Centers/free play
Meals		Snack
Transitions (specify)
Other:

5. Are there other children or adults whose proximity is associated with a high likelihood of challenging behavior? If so, who are they?
Siblings
Family member(s)
Care provider(s)
Other adults	Specify:				Teacher
Parent
Other children (specify)
Other:

6. Are there other children or adults whose proximity is associated with a low likelihood of challenging behavior? If so, who are they?
Siblings
Family member(s)
Care provider(s)
Other adults	Specify:				Teacher
Parent
Other children (specify)
Other:

7. Are there specific circumstances that are associated with the treatment?
___Asked to do something
___Given a direction
___Reprimand or correction
___Being told “no”
___Sitting near specific peer
___Change in schedule
___Getting peer/adult attention	___Seated for meal
___Playing with others
___Sharing
___Taking turns
___Playing by self
___Novel/new task
___One-to-one time with adult
Other:

8. Are there conditions in the physical environment that affect behavior(e.g., too warm, too cold, too crowded, too hot)
___Yes (specify)
___No

9. Are there circumstances that occur on some days are more likely?
___Illness
___Allergies
___Physical condition
___Change in diet	___No medication
___Change in medication
___Hunger
___Parties or social event
Other:

| Additional comments not addressed: | |

With a high likelihood of challenging behavior?
Transition
End of preferred activity
Removal of preferred item
Beginning of non-preferred activity
Activity becomes too long	Structured time
Unstructured time
Down time (no task specified)
Teacher is attending to someone else
During a non-preferred activity

What are conditions that may make challenging behavior more likely (e.g., so much noise, too chaotic, weather conditions)?

Are there other days that may make challenging behavior more likely?
Change in caregiver
Fatigue
Change in routine
Parent not home	Home conflict
Sleep deprivation
Stayed with noncustodial parent