CIMS: Date:

BPS Des Moines Public Schools Department of Student & Family Services Behavioral Support Plan: Monitoring

Name: Problem Statement What is the target behavior?

DOB:

Date:

What about the behavior is problematic? What is expected? What standard was utilized? What is the level of performance before intervention? (Baseline) What is the discrepancy between expected and actual behavior? Goal (specify time, condition, behavior, and criterion)

Parental Participation (Summarize the parents engagement in this process)

Measurement Strategy Method: Conditions (when and how): Schedule: Person(s) responsible for Data Collection: Person(s) responsible for data summary/analysis: Decision Making Plan described on Strategies page Follow-up Date(s): Intervention Outcome Level of Performance After Intervention: Discrepancy: Less discrepancy from peers/standard More discrepancy from peers/standard Insufficient data for decision making Intervention Status: Problem resolved Problem not resolved, redesign or modify intervention Problem not resolved, continue or revise intervention and determine entitlement for special education Intervention successful but resources needed to maintain intervention are beyond what is reasonable in general education. Continue or revise the intervention and determine entitlement for special education.