1. Environmental : Change of Physical Environment (new room, new place)
Change of People in the Physical Environment

Please State Details (which people, how many, etc.)

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2. Possible Sensory Triggers: Sounds Taste Smell Touch Visual Temperature

Please State Details:

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3. Other Factors to Consider as Possible Causes (did any of these changes occur?)

Insistence on Sameness of Schedules and Routines
Lack of Social Awareness - Does not pick up on Social Cues
Unable to Communicate Illness or Injury
Frustration at a Task or Following a Rule

Please State Details:

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4. This Tantrum occurred “out of the blue” with no clearly identifiable rhyme or reason.

Please State Details:

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Part II . State the Behavior

1. Approximate DURATION of Tantrum (in minutes)

0 .... 5 ....10 ....15 .... 20 .... 25 .... 30 .... 35 ....40 .... 45 .... 50 .... 55 .... 60 +

2. Exact Behavior of the Tantrum (circle all which apply)

PASSIVE
Pouting Sulking ....“Go Limp”.... Crying/Sobbing....Clinging to Objects

Other (please state) _____________________________________________________

AGGRESSIVE
Yelling.... Shouting.... Screaming.... Cursing.... Hair Pulling

....Hitting.... Biting.... Kicking Throwing Objects (large? small?)

Other (please state) _______________________________________________________

Body Position: Laid in the Floor.... In Chair/At Desk.... Ran Around the Room.... Under a table or desk.... Ran Toward a Person.... Stood in Middle of Room

Other:(please state)__________________________________________________

3. Degree of SEVERITY of the Behaviors

Degree of “Viciousness” of Aggressive Behaviors

1.... 2.... 3.... 4.... 5.... 6.... 7.... 8.... 9.... 10
Did not Leave a mark-- Bruised Skin -- Drew Blood

Hair Pulling Degree of “Viciousness”

1.... 2.... 3.... 4.... 5.... 6.... 7.... 8.... 9.... 10
Touched Hair -- Tugged Hair -- Ripped Hair from Scalp

NO physical confrontation to report.

Part III. Consequenses

Now this part does not mean what punishment did the student receive for this “acting out” behavior. Consequences here just mean what did the adult do immediately following the temper tantrum?

For example: ignored the tantrum, removed the student to a renewal area, used a restraining hold such as a basket hold, etc.

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