<p> FBA-Page 1 of 2 for Preschool and School Age New Hanover County Schools Functional Behavioral Assessment (FBA)</p><p>Name______Review Student’s Strengths: Review Target Behavior: (See PBS 4)</p><p>ID# ______Date of Birth______Meeting Date______</p><p>A Antecedents B Behavior C Consequences Check factors noted prior to target behavior. Summarize behavior at each level of intensity Check events that typically follow the target behavior. from the data gathered during the last 2 weeks on the Frequency Data Sheet. Be specific, and look for patterns. FBA-Page 2 of 2 for Preschool and School Age Name: ______ID #: ______</p><p> Physical / medical (discomfort / change in Mild:  Internal / intrinsic pleasure meds?) ______ Teacher / adult attention  Social / emotional (with whom / negative ______interaction / social skill deficit?)  Peer attention ______ Communication (understand instructions /  Verbal warning / reprimand make needs known?) ______Moderate:  Loss of privilege (what kind? school? home?)  Environmental / classroom (over-stimulated / ______noisy / crowded?)  Time out (where? how long?) ______ Academic / instructional (too easy / too difficult  Detention (how long? what kind?) (include #) / not interested / unorganized / large group / ______independent work?)  Removal from class (bounced) (include #) ______ Office referral (include #)  Setting events (response to command / Severe: ______transition / unstructured / change in routine/  Restitution (what kind?) bus / time / person / subject?) ______ In school suspension (how long?) ______ Home (change in home / family dynamics?)  Out of school suspension (how long?) ______ Other  Legal charges (what kind?) ______ Bus referrals/suspensions (include #) ______ Other ______Function of Target Behavior Hypothesis What does the student gain from this behavior? What variables appear to trigger this behavior? What does the behavior look like? What seems to reinforce this behavior? FBA-Page 2 of 2 for Preschool and School Age Name: ______ID #: ______</p><p> Attention from: Example:  Peers ______When Johnnie is in small group instruction and/or gym (SETTING) and does not get his way (ANTECEDENT / CONTEXT), he typically responds by shoving and/or using  Staff ______threatening language (BEHAVIOR) to gain attention (FUNCTION).  Preferred adult ______Fill in the blanks to complete your hypothesis:</p><p> Power: When student is ______ Control ______(SETTING) and ______(ANTECEDENT / CONTEXT)  Intimidation ______he/she typically responds by ______ Vengeance ______(BEHAVIOR) to gain ______(FUNCTION)  Escape / avoidance of:  Activity or task ______If this is a specific/one time incident that is being considered for long- term suspension, then describe the incident.  Particular person ______</p><p> Classroom ______</p><p> Self-stimulation to reduce :  Anxiety ______</p><p> Fear ______</p><p>For a list of meeting participants, see SST/IAP Attendance Log or IEP Page 1.</p>