District School Board of Pasco County
CONFIDENTIAL AND PRIVILEGED STUDENT INFORMATION FOR PROFESSIONAL USE ONLY
Brief Functional Behavior Assessment – Behavior Intervention Plan
Student name:
ID#:
Parent / guardian:
Gender:
Demographics
Date:
Male
Exceptionality(ies):
Primary:
Other:
Female
ELL:
Yes
Medical diagnosis, if applicable:
School:
Basic Ed:
Yes
Grade:
504:
No
PMP area:
Yes
If Yes, what area(s)?
Math
No
Yes
No
Reading
Science
No
Writing
Previous retention?
Yes
No
Primary:
Additional:
Medications, if applicable/known:
Team liaison / case manager:
DOB:
Retention Grade(s):
Referral source:
Previous FBA Date(s):
Other team members (name, role):
Functional Assessment
Step one: Problem Identification (Define the Problem)
Consideration: If the team has more than one problem behavior to address that are not part of a chain of behaviors which occur
together (e.g. push away from desk, stand up and call out to teacher), consider completing the Comprehensive FBA/BIP process.
What is the primary behavior of concern? (What does it look like? What is the student doing? What is the student saying?
Give an example):
Step two: Problem Analysis (Determine the Function)
Please list the student’s schedule and how likely the behavior is to occur during that activity/subject:
Activity/subject/course
Likelihood of problem
Types of activities
Teacher Name
Independent work
Whole/large group
Low
High
Small group
Transition
Non-academic
task
Activity with peer
1
2
3
4
5
6
Low
1
High
2
3
4
5
Low
1
High
2
3
4
5
Low
1
2
3
4
5
2
3
4
5
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High
2
3
4
5
Low
1
6
High
Low
1
6
High
Low
1
6
6
High
2
3
4
5
6
1
Independent work
Small group
Non-academic task
Whole/large group
Transition
Activity with peer
Independent work
Small group
Non-academic task
Whole/large group
Transition
Activity with peer
Independent work
Small group
Non-academic task
Whole/large group
Transition
Activity with peer
Independent work
Small group
Non-academic task
Whole/large group
Transition
Activity with peer
Independent work
Small group
Non-academic task
Whole/large group
Transition
Activity with peer
Independent work
Small group
Non-academic task
Whole/large group
Transition
Activity with peer
Antecedents
What happens immediately before the behavior occurs?
Being told work is wrong
Removal of preferred item
Denied Access to item/activity
Reprimand or correction
“Down time” (no task specified)
Request to start task
End of preferred activity
Schedule change
Novel task
Setting change
Peer behaviors:
Start of non-preferred activity
Other /Additional observation:
Student is alone
Teacher is attending to other students
Told “no” or “wait”
Transition
Unstructured activity
Consequences
What do other (adult or peers) immediately say or do after the student engages in the problem behavior?
Activity changed
Natural consequences (Specify)
Sent to behavior specialist/counselor
Activity terminated
Peer reaction (Specify)
Sent to office
Assistance given
Physical prompt
Sent to time-out
Calming/soothing
Physical restraint
Teacher positive attention
Chair time-out
Reminded of rules
Teacher negative attention
Change setting
Removal of reinforcers
Verbal redirect
Delay in activity
Seclusion
Verbal reprimand
Ignore
Sent home
Other /Additional observation:
Function
Based on the Problem Analysis, why is the behavior occurring? (What is the payoff? What rewards /maintains the behavior?)
Consideration: If the team has identified more than one possible function for a behavior, complete the Comprehensive FBA/BIP
process.
To get something
To get away from / avoid something
Peer attention
Teacher attention
Peer attention
Teacher attention
Item
Activity
Item
Activity
Sensory stimulation
Sensory stimulation
Hypothesis
What is your best guess / hypothesis for why the behavior is occurring? The replacement behavior developed must allow the
student to achieve the same function as the problem behavior (e.g. escape, gain attention, etc.)
Antecedent / trigger
When…
Problem behavior
The student will…
In order to…
Replacement behavior
Instead, the student will …
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Consequence / pay off
2
Behavior Intervention Plan
Demographics
School:
Student name:
ID#:
Plan date:
Implementation date:
Grade:
Revision date:
DOB:
Discontinued date:
Target Behaviors
Directions: Develop measureable goals for the replacement behavior and problem behavior.
Replacement behavior goal:
Problem behavior goal:
Step three: Intervention Development and Implementation (Determine by the Function)
Interventions
Antecedent interventions
What will you do to prevent the behavior from occurring?
Modify amount of work
Change who is around
Increased home/school communication
Modify presentation of work
Provide extra help
Other:
Provide choices
Increase supervision
Other:
Teaching Interventions
Asking for help
Asking for a break
Managing feelings
What desired skills will you teach to replace the problem behavior?
Asking for alone time
Problem solving
Asking for attention
Other:
Asking for an activity
Other:
Consequence / Reinforcement interventions
How will you maximize the reinforcement of replacement behavior by providing the same outcome (i.e. function) as the problem
behavior?
Provide attention
Provide down time
Other:
Provide breaks
Allow student to pick class activity
Other:
Provide work choice
Preferred activity or object
Other:
How will you minimize the reinforcement of problem behavior so that the student will no longer obtain the same outcome?
Provide consistent verbal praise for
Acknowledge when student is doing the right thing
new skill
Other:
No eye contact or response/ ignore
Prompt appropriate behavior
Other:
Offer assistance with academics
Reward other students who are working/on task
Other:
What will be done?
Example - When the student calls out without
permission, the teacher will ignore John and
praise students immediately surrounding John
who are appropriately seeking permission to talk,
ask questions, etc.
Intervention and Fidelity Plan
Who is
When will it Where will
responsible?
occur?
it occur?
Teacher
Instructional
assistant
Daily
Classroom
Fidelity plan:
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How will support be provided for the
intervention?
Guidance will conference with teacher once a week
to ensure understanding and fidelity of intervention
Data collection
Directions: Record the date below each day’s label. Circle a rating for desired behaviors and problem behaviors. Set anchor
points for the behaviors based on the student’s current levels of replacement behaviors and problem behaviors.
For example
Replacement behavior: Asking for a break
5 = more than 10 occurrences, 4 = 7-9 occurrences, 3 = 4-6 occurrences, 2 = 1-3 occurrences, 1 – No occurrences
Problem behavior: Hitting teacher and staff
5 = more than 20 occurrences, 4 = 15-19 occurrences, 3 = 10-14 occurrences, 2 = 5-9 occurrences, 1 – Less than 5
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10
Insert date Insert date Insert date Insert date Insert date Insert date Insert date Insert date Insert date Insert date
Replacement behavior - Define anchor:
5
5
5
5
5
5
5
5
5
5
4
4
4
4
4
4
4
4
4
4
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
Problem behavior - Define anchor:
5
5
5
5
5
5
5
5
5
5
4
4
4
4
4
4
4
4
4
4
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
Step four: Response to Intervention (Review the Fidelity and Student Data)
Response
Date:
Rate the fidelity of implementation.
As Planned
Inconsistent
Not as planned
If fidelity is inconsistent or not as planned (above), develop plan to increase fidelity:
Retrain/coach teacher/implementer on the plan
Modify the interventions so that they are feasible for implementation (Revise Intervention and Fidelity Plan and collect
additional data)
Develop different interventions that match the hypothesis and are more feasible for the teacher to implement (Revise
Intervention and Fidelity Plan and collect additional data)
Date of follow-up meeting to review additional fidelity data (Do not proceed unless fidelity is As Planned)
Replacement Behavior?
No change
Increase
Decrease
Inconsistent
Problem Behavior?
No change
Increase
Decrease
Inconsistent
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Decision
Maintain intervention plan – Explain:
Modify plan from choices below
Conduct a Comprehensive FBA/BIP
Establish new goal/increase criterion
Expand the interventions (additional people, settings, routines)
Fade intervention components (Revise Intervention and Fidelity Plan, collect additional data and complete Step
four: Response to Intervention)
Discontinue Tier III supports and continue or develop Tier II supports – Explain:
Cc: Parent
Cumulative folder
Teacher
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