Behavior Rating Scale

Student: Staff Member(s): Day & Date:

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Intervals

10 to 10:30

10:30 to 11

11 to 11:30

11:30 to 12

12 to 12:30
9:30 to 10

12:30 to 1
8:45 to 9

9 to 9:30

1 to 1:30

1:30 to 2

2 to 2:30

2:30 to 3

3 to 3:30
(list primary activity)
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Notes
Target Behaviors

Thrusting hips
Objects People
5+ times 5+ times 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
1-2 1-2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
0 times 0 times 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Communication Help Help Help Help Help Help Help Help Help Help Help Help Help Help
+ – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I
LOS_____ + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I
+ – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I
B B B B B B B B B B B B B B
Help or Break + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I
+ – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I
+ – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I + – I
# of minutes engaged
24-30 mins 5 5 5 5 5 5 5 5 5 5 5 5 5 5
18-23 4 4 4 4 4 4 4 4 4 4 4 4 4 4
12-17 3 3 3 3 3 3 3 3 3 3 3 3 3 3
6-11 2 2 2 2 2 2 2 2 2 2 2 2 2 2
0-5 mins 1 1 1 1 1 1 1 1 1 1 1 1 1 1
# of minutes of non-
compliance (includes
aggressive behaviors)
24-30 mins 5 5 5 5 5 5 5 5 5 5 5 5 5 5
18-23 4 4 4 4 4 4 4 4 4 4 4 4 4 4
12-17 3 3 3 3 3 3 3 3 3 3 3 3 3 3
6-11 2 2 2 2 2 2 2 2 2 2 2 2 2 2
0-5 mins 1 1 1 1 1 1 1 1 1 1 1 1 1 1

# of grabs (circle if on
a student)

# of pinches (circle if
on a student)

# of bites (circle if on
a student)

updated 2/26/18
Thrusting hips – Objects or People – # of times XXX puts hips against object/person and moves hips into the
object/person
o One incident is when he starts until he stops, which is typically when staff interrupt and redirect him to
another activity

 Communication – Attempts at asking for help or break. I for independent w/out prompts, + when done with
current LOS and – when not done without LOS

 Physical Aggression – Mouthing/biting arm; Throwing body against the wall; Hitting head toward wall
(Blocking head from wall with arm)

 # of Minutes – # of minutes spent out of 30 minutes that XXX…

o Engaged – Participated (sitting, eyes on task and doing task when prompted) in structured activities
like circle time, snack, work, etc.

 Pinching, grabbing or biting – Grabbed, pinched and/or bit staff or peers

updated 2/26/18