Fba Teacher Interview Form

FBA Teacher Interview 1

FBA TEACHER INTERVIEW FORM

Date: ______Student: ______Grade: ______Teacher: ______Class: ______

1. Target behavior: ______

2. When did the problem behavior(s) start within the school year? ______

3. How often does the behavior occur? (e.g. daily, weekly)______

4. How long does it last? ______

5. How intense is the behavior? (please circle and comment) can be handled with redirection/reprimand requires multiple redirection/reprimand requires removing student from environment requires additional staff assistance disruptive to students nearby disruptive to entire class ______

6. Does there appear to be any pattern of the occurrence of the behavior? ______

7. What is happening when the behavior occurs? (e.g. in the classroom) ______

8. When/where is the behavior most/least likely to occur? ______

9. With whom is the behavior most/least likely to occur? ______FBA Teacher Interview 2 10. What conditions are most likely to set-off the behavior? ______

11. Are there any signals or cues displayed by the student that occur right before? ______

12. What usually happens after the behavior? Describe how adult(s), peers, and student respond. ______

13. Why do you think he/she behaves this way? A) to obtain: ______B) to avoid: ______C) to communicate: ______

14. Does the behavior appear to be related to any of the following (please circle and comment): Skill deficit Deprivation (e.g. lack of rest, hunger) Desire for stimulation Environmental (e.g. changes in home, neighborhood) Medical complications Form of discomfort (e.g. headaches, ear infection, allergies) Attention seeking Family Stressors (e.g. drug/alcohol, divorce, separation, death) ______

15. What behavior(s) might serve the same function for the student that is appropriate with the social/environmental context? ______

16. What other information might contribute to creating an effective intervention plan (medical/social conditions)? ______

Additional Comments: FBA Teacher Interview 3 BAF 3

VIII. Summary of previous interventions attempted:

Target behavior #1: ______

Intervention Date Implementer Outcome