FUNCTIONAL BEHAVIORAL ASSESSMENT
Name:
Address:
Parent:
Grade:
School:
Participants:
ID Number:
Date of Birth:
Phone number:
Date:
This Functional Behavioral Assessment replaces ____ (insert statement of past FBA date.__
I. Purpose:
This assessment is being completed as part of the IEP process to review progress, identify
specific services and needed interventions, and to make future program recommendations.
Information obtained within this functional behavioral assessment was gathered through:
(Insert list of sources used to develop this document).
II. History
(This section is optional and can be written as one section or broken into separate segments
if the writer prefers.)
(Insert student’s background information: summary of services currently receiving; school
history, types of supports; any significant incidents that are relevant to this FBA, sensory/health
history, history of behavior(s) of concern)
Learner Strengths and Characteristics:
Previous Interventions/Effectiveness
(Include all previous interventions and a comment on their degree of effectiveness. This could be made into
a chart for easy reference. )
Previous Interventions
Example: Planned Ignoring
Effectiveness
Example: Not effective
III. Data Collection and Analysis
Specific Description of Behaviors of Concern
(Describe each behavior in clear, observable, measurable terms. Indicate frequency,
duration, and intensity.)
Factors that Impact Behavior (Include Analysis of any classroom behavior (ABC, daily data
collection, graphs)
FUNCTIONAL BEHAVIORAL ASSESSMENT
Student’s name and ID #
month/year
CONFIDENTIAL
Classroom Behavior Data Analysis (Include narrative summary of classroom data, as well
as pertinent graphs of frequency or duration,)
Antecedents that may trigger behavior
Behavior(s) of Concern
Antecedent (what happens right before)
Consequences that may maintain the behavior
Behavior(s) of Concern
Consequence
(responses of others and other
environmental results)
Student’s Response(s)
(What did the student
typically do next?)
Additional Factors Which May Impact Behavior (Include those sections which are
pertinent)
Patterns: (such as: time of day, location, instructional variables such as large
group/small groups, etc.)
Health Issues: (seizures, medication changes, allergies, etc.)
Social: (peer, staff interactions, etc.)
Environmental: (physical structure or conditions, etc.)
Family: (Change in family structure, move, etc.)
Educational History: (placement change, school district change, school attendance,
school history unless indicated in History Section on page 1)
Summary of Formal Classroom Observation (Formal classroom observations are completed
by a third party across settings or in areas where the behaviors are occurring.)
Brief Analysis of Formal Observation:
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FUNCTIONAL BEHAVIORAL ASSESSMENT
Student’s name and ID #
month/year
CONFIDENTIAL
Motivational Assessment Scale (MAS)
(Do the MAS to identify where the behavior is derived. Do not combine behaviors – the MAS
must be conducted separately on each targeted behavior. If more than one individual completes
the scale, individual raw scores should be added together and averaged to arrive at an aggregated
mean. If the scores are high in Attention or Escape, then do the Problem Behavior Questionnaire
next.
Behavior:
Sensory
Escape
Attention
Tangible
Mean score
(highest possible mean score = 6)
Rank
Brief Analysis of MAS:
Setting
Events
Adults--Attention
Adults--Escape
Behavior
Peers--Attention
Peers--Escape
Problem Behavior Questionnaire Profile
Rank
(Based on a possible
total of 18)
Brief Analysis of PBQ:
Reinforcement Survey Results:
Student Likes
Student Dislikes
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FUNCTIONAL BEHAVIORAL ASSESSMENT
Student’s name and ID #
month/year
CONFIDENTIAL
IV. Function(s) of Behavior(s)
Behaviors of Concern
Possible functions of the
behavior
(what might the student obtain,
avoid, or attempt to communicate
through the behavior)
Target replacement behaviors
(what behaviors can serve the
same function as the challenging
behavior)
Analysis (Include a narrative statement explaining the rationale for the findings
summarized in the chart above)
V. Recommendations & Conclusion
A Behavior Intervention Plan will be developed which is based on, and aligned with, the findings
in this Functional Behavioral Assessments. The object of the Intervention Plan will be to provide
the tools and structure necessary for ______ to experience success in school. The intervention
plan will entail a clear understanding and consistent implementation by all staff, and will include:



Identification of target replacement behaviors and strategies which address the
functions of the behaviors of concern;
Reinforcement of positive behaviors;
Protocols for responding to inappropriate behaviors;
The plan will be subject to on-going monitoring and review, guided by data, to ensure
effectiveness and fidelity. The Functional Behavioral Analysis will be revised or up-dated,
whenever necessary, if situations warrant.
Respectfully submitted,
_____________________________________________________________
Name
Title
Date
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