School District No. 5 (Southeast Kootenay)
FUNCTIONAL ASSESSMENT / BEHAVIOUR HISTORY
Student Name:
Grade:
Specifics of Behaviours:
Behaviour demonstrated: ___________________________________ Date: _______________
Frequency:
Duration:
Intensity:
Activity/class:
Time of day:
Physical surroundings:
With which peers/adults:
Behaviour demonstrated: ___________________________________ Date: _______________
Frequency:
Duration:
Intensity:
Activity/class:
Time of day:
Physical surroundings:
With which peers/adults:
Behaviour demonstrated: ___________________________________ Date: _______________
Frequency:
Duration:
Intensity:
Activity/class:
Time of day:
Physical surroundings:
With which peers/adults:
Behaviour demonstrated: ___________________________________ Date: _______________
Frequency:
Duration:
Intensity:
Activity/class:
Time of day:
Physical surroundings:
With which peers/adults:
September 2007
Page 1
Student Response / Motivation:
Describe the student’s response when asked to perform a difficult task?
Describe the student’s response when there is a change in his/her schedule or routine?
Describe how the student responds in individual/one-to-one situations?
Describe how the student responds in small group situations?
Describe how the student responds in large group situations?
Describe how the student demonstrates positive behaviours (e.g. fulfills responsibilities).
Any additional comments:
September 2007
Page 2