FBA 1 of 1
FBA 2 of 2
EDUC 624
FUNCTIONAL BEHAVIORAL ASSESSMENT
STUDENT INFORMATION: IEP Duration Dates: From: ____________ To: ____________
Student’s Last Name: First: Middle:
Student number:
School:
Grade:
Date of Birth:
Reason for assessment:
Current Educational information: (Specify developmental, cognitive, and communication abilities review the following: discipline profile, attendance, psychological evaluation, work samples, IEP progress)
Relevant family/medical history:
PROBLEM BEHAVIOR (attach all completed data forms)
Problem Behavior
Observable/Measurable Definition
How Often
(Frequency)
How Long (Duration)
Data
(include collection methods, source and dates)
Student’s Name: ____________________________________________________________ Student #:_______________
ANTECEDENT (summarize what happens BEFORE each identified behavior – utilize data analysis)
What situations seem to trigger the problem behavior(s)? Identify by problem behavior 1 and/or 2.
________ Lack of Social Attention ________ Interruption in routine
________ Demand/Request ________ Negative social interaction
________ Difficult Task ________ Consequences imposed for negative behavior
________ Transition (Task) _______ Student Performing Below Grade Level (Areas: )
________ Other ____________________________________________
When is/are the problem behavior(s) most likely to occur? (days/times)
When is/are the problem behavior(s) least likely to occur? (days/times)
Could the problem behavior(s) be related to educational or skill deficits? Yes _____ No_____
(Check all that apply)
_____ Academic ______ Social
_____ Communication ______ Sensory Processing
Explain/Describe how the problem behavior(s) could be related to the areas checked above:
SETTING EVENTS (related issues that contribute to each identified problem behavior)
Setting Events: Are there specific conditions, events, or activities that increase the problem behavior? Identify by problem behavior 1 and/or 2 (setting events are social, physiological and environmental factors.).
__ Independent Work __ Unstructured activity/setting ___ Academic Failure
__ Group Instruction __ Peer attention ___ Medication Issues
__ Crowded Setting __ Adult attention ___ Illness
__ Transition
Other:
Student’s Name: ____________________________________________________________ Student #:_______________________
CONSEQUENCES- (summarize what happens right AFTER the behavior occurs)
Describe what usually happens right after the behavior(s) occurs. Identify by problem behavior 1 and/or 2.
What does the staff do?
_______ Behavior Ignored _______ Sent to office
_______ Reprimand/Warning _______ Communication with home
_______ Redirect _______ In-School Suspension
_______ Time Out ________ Out-of-school suspension
_______ Loss of incentives/privileges ________ Other
What do other students do?
What activities/events happen or stop happening? Are any objects obtained or avoided or any conditions gained or avoided?
BEHAVIOR INTERVENTIONS (List interventions currently in place; attach samples)
Intervention
Location
Implemented By
How Often?
Effectiveness
(based on current behavior data)
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6
Low High
1 2 3 4 5 6
Student’s Name: ____________________________________________________________ Student #:_______________________
FUNCTION OF BEHAVIOR (proposed hypothesis of the problem behavior) Identify by problem behavior 1 and/or 2.
Get/Obtain
Escape/Avoid
_______ Adult attention
_______ Peer attention
_______ Activity/object
_______ Get sent to a preferred adult
_______ Control/Power
_______ Self-stimulation/Sensory
_______ Other desirable condition (define):
_______ Adult attention
_______ Peer attention
_______ Activity/work/object
_______ Avoid a demand or request
_______ Avoid a person
_______ Escape the classroom/setting
_______ Escape the school
_______ Sensory (pain, hunger, etc)
_______ Other Undesirable condition (define)
SUMMARY STATEMENT (includes antecedents, behavior and function):
The Team should carefully develop a statement using the following format that summarizes the
information in this FBA.
When (antecedents to the behavior) occurs, the student does (specific behavior of concern), in order to
get/obtain/escape/avoid (the perceived function of the behavior).
Based on the FBA, the student requires the following: ___ Behavior Goal Page and BIP
___ Classroom Management Strategies
Summer 2023
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