Functional Assessment Interview Tool: Summary Version

Student: Kevin Jackson Date Completed: March 2006

Problem Behavior and Definition Check off the level of List all of the behaviors team members reported. To the greatest extent possible try to group intensity team behaviors by common topography (e.g., hitting, punching, pushing are all examples of physical members reported aggression) the behaviors occur

Classroom disruption: talks to peers, hums, falls out of his seat, talks back to teachers, argues about assignments or directions, unprepared to class, doesn’t complete assignments, gets off tasks easily, Redirectable talks to peers, gets out of seat when he should be doing work, not following directions, not doing Repeated school work, disrupting class, uses equipment inappropriately, makes noises, engages in activities Unmanageable other than what he should be doing, yelling out, un prepared for class, doesn’t initiate work, refuses to do what he is asked to do, does not pay attention, is rarely prepared Physically and verbally aggressive with peers, getting into fights, pushing peers when he is upset Redirectable Repeated Unmanageable

Redirectable Repeated Unmanageable What Works Well for the Student?

Check off all the positives and successful learning conditions reported by team members. Write in reported preferences.

Positive Things About the Student Student’s Preferences or Interests Successful Learning Conditions

Friendly  Art Lessons/activities that: Helpful  Sports: basketball, football, Sociable skateboarding Encourage reflective thinking Organized  Comic books Use analytical skills Natural leader  Video games Involve building/constructing Liked by peers  Being the center of attention Involve applying concepts or Has lots of friends  Computers and electronics formulas Self starter Involve experiments or testing  Science Socially aware Use creative writing  Interacting with people – Follows directions Utilize the computer opportunities to socialize Honest Allow for artistic expression of Easygoing  Hanging out with friends concepts Attentive to instruction  Watching movies Kind to adults  Family dog Other: when he can do or learn Kind to other students  Listening to music something of interest to him Good sense of humor Other: when you use a highly Has a positive preferred incentive attitude/outlook Other: activities allowing for Good communication creative thinking skills Other: small group activities Hard worker Other: working with him 1:1 Other: athletic Other: does better when tasks are Other: asking good questions given to him one step at a time or Other: computer and electronics are organized for him Other: Other: when he doesn’t have a lot of stuff to keep track of What Contributes to Occurrences of Problem Behavior?

Summary of antecedent triggers

Number of Antecedents Number of Antecedents Responses Responses ______When asked to do a chore or helping task ____4__ Transition at the beginning of a class/routine/activity ___4___ When it is time to do academic work ____4__ Unstructured situations or settings ___1___ When told to do something non preferred ____2__ When given a direction to follow ___1___ When held to a time limit (e.g., curfew or time for class ____2__ When corrected ___0___ Tasks that are difficult or confuse the student ____2__ When he/she can not have something they want ___1___ When working/playing/entertaining independently ____0__ Preferred peer group present ___0___ When working in group activities ____1__ When given an ultimatum ___2___ Not prepared with materials ____0__ When he or she is told “no” or stop ___2___ Multi-step work or projects ____1__ When there is a change in routine ___3___ Lecture: with note taking OR without note taking ____0__ When adult attention is on others ___1___ Public response required (e.g., read aloud) ____0__ When there are visitors to the setting ___2___ Being teased or being joked around with ____1__ Other: when it’s time to go to school

Summary of consequences/responses/strategies tried

Number of Consequences/Responses Number of Consequences/Responses Responses Responses ___3___ Give a non verbal cue (e.g., look at student) ____0__ Let the student have what they are asking for ___6___ Verbally correct the student privately ___3___ Deduct points from an assignment __5____ Verbally correct the student publicly __3____ Send the student to an administrator __4____ Help the student to get on task __0___ Other students laugh or “egg” the student on __2____ Speak to the student after class ___0___ Give the student a pass to guidance or CST __5____ Call the student’s parents ___0___ Have the student take a break __1____ Take away recess or other free time ___2___ Teacher assigned detention __1____ Moved seat ___4___ Student gets out of or delays doing work __1____ Student – teacher conference ___4___ Provide a reminder of what is and isn’t appropriate in ___0___ Take a privilege away class ___4___ Try to explain and discuss the issue ______Other:

Summary of reasons why people think behavior is occurring

Number of Reasons Why Behavior Occurs Number of Reasons Why Behavior Occurs Responses Responses __4____ Get out of situations/work that is too hard ___2___ Get out of the situation because they are not sure of __5____ Get out of situations/work that is perceived as boring what to do or what is expected ____0__ Get out of work/class to avoid being embarrassed ___3___ Student shows off to win the validation of peers because he/she is behind peers ___1___ To get control over the situation ___3___ “Save face” in front of friends ___3___ To get the teacher to pay attention to him/her (even if ___0___ To be left alone this is negative attention) ___2___ To get something he/she wants ____0__ To get peers to pay attention to him/her ___1___ Student wants more of OR less ____0__ Have predictability to know what comes next stimulation/excitement

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