<p> Functional Behavior Assessment</p><p>Functional behavior assessment (FBA) is a process that seeks to identify problematic behaviors and to examine the interactions that cause/maintain them, to develop a working hypothesis as to the purpose of the behavior, and to suggest a positive, individualized behavior management plan.</p><p>Student: Grade: School: </p><p>Teacher(s): Date: </p><p>BEHAVIOR DESCRIPTION Please check all of the behaviors that occur frequently, and then number the top 3 most severe behaviors. In selecting these behaviors, please consider which behaviors, if changed, would likely increase the student’s classroom functioning.</p><p>Passive Behaviors Verbal Behaviors Physical Behaviors ___ tardy often ___ talking out ___ excessive movement/fidgeting ___ off-task ___ disrespect ___ out of seat ___ frustrated ___ argues ___ leaving room ___ withdrawn ___ inappropriate language ___ tantrum ___ mood swings ___ verbal threats to teacher ___ damaging property ___ not completing work ___ verbal threats to peers ___ physical threats to teacher ___ inattentive ___ physical threats to peers ___ aggression ___ not following directions ___ self-abuse ___ other Where do the top 3 (most severe) behaviors commonly occur? </p><p>Who tends to be involved? Adults: ______Peers: How long do the behaviors last? How often do they occur? </p><p>Behavioral Antecedents (Identify factors that usually precede the identified behaviors.)</p><p>Teacher Behavior/Expectations Student Conditions Environmental Factors ___ praising student ___ sleepy ___ lack of structure ___ individual instruction ___ physical complaints ___ excessive noise ___ small group instruction ___ hot/tired from PE/recess ___ crowded ___ lecture/presentation ___ medication issues ___ transition ___ independent seatwork ___ affect ______interruption in routine ___ withholding attention ___ hungry ___ unusual person present ___ giving direct order ___ working/on task ___ ending desired task ___ denying request ___ head down ___ time of day ______reprimanding ___ restless/agitated ___ back from absence ___ initiating task ___ unable to do task ___ family stressors ______inaccurate perception ___ negative peer attention ______did not understand ___ positive peer attention ______</p><p>Maintenance Factors (Identify those factors that appear to maintain or follow behavior.)</p><p>Teacher Behaviors Other Student Behaviors Consequences ___ praise/encourage ___ positive attention ___ time out ___ task removal ___ negative attention ___ lost points ___ ignoring ___ ignoring ___ conference with ______reprimand ___ isolation ___ parent called/notified ______lost activity ______lost recess ______Name: ______</p><p>What function does the problem behavior serve? (Please select the best reasons that may apply.) Function Tangible ___ get attention ___ to get access to preferred items (toys, food, etc.) ___ student want to be reprimanded ___ when something is taken away from him/her ___ to get a reaction from peers ___ when someone has something he/she wants ___ to get a reaction from teachers ___ to gain access to object/activity Escape Non-Social ___ to escape a work or learning situation ___ as a form of “self-stimulation” ___ when asked to do something (work, sit down) ___ when no one else is in the room ___ try and get people to leave him/her alone ___ when there is nothing else to do ___ to avoid a person ___ as a highly repetitive behavior even when no one else is present ___ to gain acceptance/approval/affiliation Cognitive Affective ___ due to distorted thoughts, inaccurate perceptions, ___ due to emotional factors (anxiety, depression, misrepresentation of events anger, etc.) Family Issues Modeling ___ due to family issues that play a part (divorce, ___ as a result of reflecting/copying behavior of a peer separation, new family member, etc.) model Curriculum Issues Physiological ___ when curriculum demands exceed student’s abilities ___ when student is in pain ___ when student perceives curriculum demands exceed ___ more frequently when student is ill his/her abilities ___ when there is something bothering ___ when student is not prepared for assignment him/her physically (homework) ___ when medication is not regulated (for ___ when student does not understand the expected task students who have a current medical ___ when given a repetitive or review activity prescription ___ after work is completed) ___ Other: </p><p>Now that we have information about the PROBLEM behavior, describe the student’s strengths – academic and non-academic or interpersonal:</p><p> Academic areas (list):  Good memory  Sports  Kind and/or compassionate  Dance/music/art/drams or other  Respectful toward authority  Works well with others  Respectful toward peers  Likes to be a helper  Works well with animals  Works well with computers  Works well with children  Works well with hands  Other:  Able to fix things; mechanically inclined  Supportive family  Other:  Follows directions well</p><p> Good sense of humor  Other  Speaks his/her mind</p><p>Hypothesized function of behavior: </p><p>Complete Behavior Intervention Plan and consider the following suggestions in development of the plan: What changes in the environment or teacher behaviors will be attempted? What changes in the instructional materials or techniques will be attempted? What new behaviors will be taught? Does the student have a skill deficit?</p><p>Teacher Signature</p>