Brentwood Union Free School District

Brentwood Union Free School District Brentwood, NY 11717 Functional Behavior Assessment (FBA)

Date of Assessment ______

Student Name ______ID # ______DOB ______Current School ______Teacher and/or Guidance ______Grade ______Student Address ______[ ] Brentwood [ ] Bay Shore Phone ______Parent and/or Guardian ______Agency ______Agency Address ______Agency Phone ______ext. ______Agency Contact and/or Caseworker ______

Background Information Provide a brief narrative of events and/or circumstances which led to this assessment ______

Current Educational Program This student is a [ ] Regular Education Student (not classified) [ ] Special Education Student (has a classification) If a Special Education student, current classification is ______Current Related Services: [ ] None [ ] Speech [ ] Counseling [ ] PT [ ] OT [ ] Other ______Current Placement: Student is currently placed in: [ ] General Education Program with related service(s) only [ ] Resource Room Program [ ] CWC (class within a class) setting [ ] Self-Contained Setting within district ____ level I (15:1) ____ level III (15:1) ____ level IV (12:1:1) [ ] Self-Contained Setting OOD ____ BOCES ____ Other ______Functional Behavioral Assessment Page 2

Interventions The following interventions have been implemented to address this student’s problematic behavior (attach a copy of all behavior modification programs, contracts, PPS and/or IST meeting notes, counselor’s notes, etc.): [ ] Building Wide Behavior/Conduct Plan [ ] Classroom Behavior Management Plan [ ] Individual Behavior Management Plan [ ] Behavioral Contract [ ] Modification of Curriculum (describe below) [ ] Classroom Management Strategies (describe below) [ ] In-School Counseling [ ] Peer Mediation [ ] In-School Suspension [ ] Out of School Suspension [ ] Attendance Teacher Involvement [ ] School Initiated PINS [ ] Other ______

Provide a brief description of the above noted interventions to include the outcome(s). Please note if the intervention was effective and for how long. As noted above, attach copies of any behavior plans, contracts, counselor’s notes and any other documentation related to all interventions attempted. ______

As reported by the parent(s) and/or Guardian, the following interventions have been attempted at home: [ ] outside psychotherapy [ ] carry over of school behavior plan and/or contract [ ] psychiatric intervention (medication) [ ] Parent Initiated PINS [ ] Other ______Provide a brief narrative of the above noted interventions to include the parent’s reports of the outcome. ______

Functional Behavioral Assessment Page 3a

FBA for Behavior 1 ______

Behavior Identification The following was identified as a primary problematic behavior for this student. It was agreed that this behavior is preventing this student from achieving success in their current educational setting. Provide an operational definition for this behavior. The definition must include specific descriptors of the behavior. General statements such as angry, emotional, disruptive, disrespectful, aggressive should be avoided when describing the behaviors. Operational Definition of Behavior 1: ______

Assessment Tools The following tools/techniques were used in the assessment of this behavior: [ ] Information obtained from direct observation of the student [ ] Information obtained from the student (including reinforcer preferences) [ ] Information obtained from the student’s teacher(s) / related service provider(s) [ ] Information obtained from the student’s record [ ] Information obtained from the student’s parent [ ] Motivation Assessment Scale [ ] Structured ABC Observation [ ] ABC Anecdotal Data

Provide a brief description of the above observations to include frequency, duration, intensity, and/or latency across activities, settings, people, and times of day. This will serve as the baseline for this identified behavior (note: frequency, duration, intensity and/or latency data must be included in the baseline). ______

Antecedents to the Behavior Based upon the information and data obtained from the above noted assessment techniques, what seems to be the consistent antecedent(s) to the targeted behavior. An antecedent to a behavior is the activity or event that immediately precedes the indicated behavior. The consistent antecedent(s) for this targeted behavior is/are: ______

Functional Behavioral Assessment Page 3a

Consequences of Behavior Based upon the information and data obtained from the above noted assessment techniques, what are the consequences of the targeted behavior. A consequence to a behavior is the activity or event that immediately follows the indicated behavior. List all consequences to the behavior below: ______Hypothesized Function of Targeted Behavior Select one hypothesized function of the targeted behavior based upon the information and data obtained from this assessment [ ] Medical or Physical Condition [ ] Escape or Avoidance [ ] Tangible Seeking – gaining access to item or activity [ ] Attention Seeking [ ] Sensory – engages in activity that provides a pleasant sensation [ ] Environmental factors

Summary of hypothesized function of behavior ______

Functional Behavioral Assessment Page 3b

FBA for Behavior 2 ______

Behavior Identification The following was identified as a primary problematic behavior for this student. It was agreed that this behavior is preventing this student from achieving success in their current educational setting. Provide an operational definition for this behavior. The definition must include specific descriptors of the behavior. General statements such as angry, emotional, disruptive, disrespectful, aggressive should be avoided when describing the behaviors. Operational Definition of Behavior 1: ______

Assessment Tools The following tools/techniques were used in the assessment of this behavior: [ ] Information obtained from direct observation of the student [ ] Information obtained from the student (including reinforcer preference) [ ] Information obtained from the student’s teacher(s) / related service provider(s) [ ] Information obtained from the student’s record [ ] Information obtained from the student’s parent [ ] Motivation Assessment Scale [ ] Structured ABC Observation [ ] ABC Anecdotal Data

Provide a brief description of the above observations to include frequency, duration, intensity, and/or latency across activities, settings, people, and times of day. This will serve as the baseline for this identified behavior (note: frequency, duration, intensity and/or latency data must be included in the baseline). ______

Antecedents to the Behavior Based upon the information and data obtained from the above noted assessment techniques, what seems to be the consistent antecedent(s) to the targeted behavior. An antecedent to a behavior is the activity or event that immediately precedes the indicated behavior. The consistent antecedent(s) for this targeted behavior is/are: ______

Functional Behavioral Assessment Page 3b

Consequences of Behavior Based upon the information and data obtained from the above noted assessment techniques, what are the consequences of the targeted behavior. A consequence to a behavior is the activity or event that immediately follows the indicated behavior. List all consequences to the behavior below: ______Hypothesized Function of Targeted Behavior Select one hypothesized function of the targeted behavior based upon the information and data obtained from this assessment [ ] Medical or Physical Condition [ ] Escape or Avoidance [ ] Tangible Seeking – gaining access to item or activity [ ] Attention Seeking [ ] Sensory – engages in activity that provides a pleasant sensation [ ] Environmental factors

Summary of hypothesized function of behavior ______

Functional Behavioral Assessment Page 4 Agreement The below have participated in the Functional Behavior Assessment for this student and have come to an agreement on the hypothesis of the function of the targeted behavior(s) and/or the effects the environment plays in maintaining the targeted behavior(s). It is understood that as a result of this FBA, a Behavior Intervention Plan (BIP) will be developed to address the targeted behavior(s) in relation to the hypothesized function of the behaviors and/or the effects of the environment.

Team Members (please print name) Signatures of Team Members Date

______/____/____

Attachments: Informed Consent Summary of Parent Conference (if parent did not attend the FBA meeting) Revised 10/1/07