Miami-Dade County Public Schools 
                                        Multi-Tiered System of Supports (MTSS) 
                                         Tier 3 Problem Behavior Questionnaire 
                                                                   
                                                                   
                                                      Respondent Information 
                                                                     
               
              Student________________________ ID#_________ DOB_______ Sex: M    F       IEP:  Y    N 
               
              School Name ______________________________________       School Loc. # ___________ 
               
              Teacher_________________________________ Grade___________ Date_______________ 
               
              Interviewer___________________________________ Telephone______________________ 
               
            Student Behavior: 
            Please briefly describe the problem behavior: 
            ____________________________________________________________________________________________
            ____________________________________________________________________________________________
            ____________________________________________________________________________________________
            ____________________________________________________________________________________________
            ____________________________________________________________________________________________
            ____________________________________________________________________________________________
            ____________________________________________________________________________________________ 
             
               
              DIRECTIONS: Keep in mind a typical episode of the problem behavior, circle the frequency (percentage of    
                                     the time) the following statements are true. 
             
             
                                                              Never  10%   25%  50%  75%  90%  Always  
                                                                       
                 
                1.  Does the problem behavior occur and         0       1       2      3       4       5      6 
                    persist when you make a request to 
                    perform a task? 
                     
                2.  When the problem behavior occurs do         0       1       2      3       4       5      6 
                    you redirect the student to get back to 
                    task or follow rules? 
                     
                3.  During a conflict with peers, if the        0       1       2      3       4       5      6 
                    student engages in the problem behavior 
                    do peers leave the student alone? 
                     
                4.  When the problem behavior occurs do         0       1       2      3       4       5      6 
                    peers verbally respond or laugh at the  
                    student? 
                     
                5.  Is the problem behavior more likely to      0       1       2      3       4       5      6 
                    occur following a conflict outside the 
                    classroom (e.g., bus write up)? 
                                                                       
                 
                                                               1                                                                               FM-7678 Rev. (01-20)
                                                                                                                               
                                                                                                                        
                                                              Never  10%   25%  50%  75%  90%  Always
                 
                6.  Does the problem behavior                     0      1       2       3       4       5       6 
                    occur to get your attention when you  
                    are working with other students? 
                     
                7.  Does the problem behavior occur in the        0      1       2       3       4       5       6 
                    presence of specific peers? 
                     
                8.  Is the problem behavior more likely to        0      1       2       3       4       5       6 
                    continue to occur throughout the day 
                    following an earlier episode?                                                       
                 
                                                                 
                9.  Does the problem behavior occur during        0      1       2       3       4       5       6 
                    specific academic activities? 
                     
                10. Does the problem behavior stop when           0      1       2       3       4       5       6 
                    peers stop interacting with the student? 
                     
                11. Does the problem behavior occur when          0      1       2       3       4       5       6 
                    peers are attending to other students? 
                     
                12. If the student engages in the problem         0      1       2       3       4       5       6 
                    behavior do you provide one-to-one  
                    instruction to get the student back on-task? 
                     
                13. Will the student stop doing the problem       0      1       2       3       4       5       6 
                    behavior if you stop making requests or 
                    end an activity? 
                     
                14. If the student engages in the problem         0      1       2       3       4       5       6 
                    behavior, do peers stop interacting 
                    with the student? 
                     
                15. Is the problem behavior more likely to        0      1       2       3       4       5       6 
                    occur following unscheduled events  
                    or disruptions in classroom routines? 
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                     
                                                             2                                                                                  FM-7678 Rev. (01-20) 
                                                                                    
                                                   Problem Behavior Questionnaire Profile 
                         
               Directions:  On the table below, circle the frequency rating given for each of the 15 questions.  
                
                   
            Payoff                           PEERS                                             ADULTS                            Setting Events 
                                Escape                   Attention                  Escape                  Attention 
                             Question #                Question #               Question #                Question #                Question #  
                           3       10      14          4      7        11       1       9      13         2      6       12         5       8        15 
            ______ 
            Always         6        6       6          6       6       6        6       6       6         6       6       6         6       6       6 
             
            90%            5        5       5          5       5       5        5       5       5         5       5       5         5       5       5 
             
            75%            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 
            50% 
                           2       2        2         2       2       2         2       2       2         2       2       2        2       2       2 
            25% 
                           1       1        1         1       1       1         1       1       1         1       1       1        1       1        1 
            10% 
                           0       0        0         0       0        0       0       0        0        0       0        0        0       0        0 
            Never 
                         Total ______of 18         Total ______of 18        Total ______of 18         Total ______of 18         Total ______of 18 
                     
                     
                    Comments: 
                    _____________________________________________________________________________________
                    _____________________________________________________________________________________
                    _____________________________________________________________________________________
                    _____________________________________________________________________________________
                    _____________________________________________________________________________________ 
                     
                    Source: Lewis, T.J., Scott, T.M., & Sugai, G. (1994). The problem behavior questionnaire: A teacher-based 
                    instrument  to  develop  functional  Hypotheses  of  problem  behavior  in  general  education  classrooms. 
                    Diagnostique, 19 (2-3) 103-115. 
                                                                          3                                                                                   FM-7678 Rev. (01-20)