ABC Checklist

Student Name:____________________
Date Time

Teacher: ________________ Consequence ___Ignored ___Used proximity ___Nonverbal cue ___Verbal warning ___Changed assignment ___Redirected ___Loss of privileges ___Gave time out ___Referral Duration ___< 1 min. ___ 1-5 min. ___ 5-10 min. ___ 10-30 min. ___ 1/2 -1 hr. ___ >1 hr.

Antecedent ___Alone ___With peers ___Preparing for outing ___Ending an activity ___Participating in group ___Asked to do something ___Asked/told not to ___Transitioning ___Working on academics ___At recess ___Being ignored ___At lunch ___Given a warning ___About to begin new activity ___Other

Behavior
___Refusing to

follow directions ___Disrupting class ___Making verbal threats ___Hurting self ___Destroying property ___Screaming/ Yelling ___Refusal to complete work ___Throwing/ Kicking ___Other

Date

Time

Antecedent ___Alone ___With peers ___Preparing for outing ___Ending an activity ___Participating in group ___Asked to do something ___Asked/told not to ___Transitioning ___Working on academics ___At recess ___Being ignored ___At lunch ___Given a warning ___About to begin new activity ___Other

Behavior
___Refusing to

Consequence ___Ignored ___Used proximity ___Nonverbal cue ___Verbal warning ___Changed assignment ___Redirected ___Loss of privileges ___Gave time out ___Referral

Duration ___< 1 min. ___ 1-5 min. ___ 5-10 min. ___ 10-30 min. ___ 1/2 -1 hr.

follow directions ___Disrupting class ___Making verbal threats ___Hurting self ___Destroying property ___Screaming/ Yelling ___Refusal to complete work ___Throwing/ Kicking ___Other

___ >1 hr.