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	___Seated for meal
___Given a direction	___Playing with others
___Reprimand or correction	___Sharing
___Being told “no”	___Taking turns
___Sitting near specific peer	___Playing by self
___Change in schedule	___Novel/new task
___Getting peer/adult attention	___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 that are more likely?
___Illness	___No medication
___Allergies	___Change in medication
___Physical condition	___Hunger
___Change in diet	___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 associated with a high likelihood of challenging (so much noise, too chaotic, weather conditions)?

Not other days that may make challenging behavior
Change in caregiver	Fatigue
Change in routine	Parent not home
Home conflict	Sleep deprivation
Stayed with noncustodial parent