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1342.12 Companion
July 12, 2017
Page 142
Part 2 (Function)
Name: ________________________________________________________ Date: __________________
Specify ECOLOGICAL EVENTS that may influence behavior.
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Disruption to Routine(s)
(Describe either home or school routines that influence behavior.)
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Medical Complications
(i.e., ADHD, asthma, allergies, seizures, etc.) Medications (List medication,
dosage, and possible side effects.)
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Sleep or Dietary Factors
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Characteristics of Disability
(List any behaviors that may be displayed that are characteristic of the
student’s identified or suspected educational disability.)
Specify HYPOTHESIZED FUNCTION for each area checked below.
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Communication Need(s)
(What is the child attempting to communicate?)
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Escape/Avoidance
(If a skill deficit, identify academic or social skill being avoided.)
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Attention/Control
(Identify the adult(s) or peer(s) from whom the student is attempting to gain
attention.)