Date

Individual's Name

Observer's Name

Relationship to Individual

Behavior Description

Frequency of Behavior

Duration of Behavior

• Less than 5 minutes

• 5-10 minutes

• 10-15 minutes

• 15+ minutes

Triggers/Antecedents

When does the behavior typically occur?

Behavior Location

Where does the behavior usually happen?

Responses/Consequences

What typically happens after the behavior?

Have you tried any strategies to address the behavior?

Additional Notes