FBA PLANNING FORM
-Sources of InformationSTUDENT NAME:
FBA INITIATION DATE:
Instructions:
Use this form to document all sources of information BEFORE
completing the FBA. First, describe the one inappropriate behavior
that was identified for the FBA (all FBA information should be
collected on that behavior). Then, document all sources of
information and indicate if you are reviewing existing data or if
new data are needed. Complete both pages of this form. At a
minimum, the FBA sources of information should at least include
the 5 required sources below. Finally, finish gathering all necessary
information and data before completing the FBA form with the
team. Attach this form with all documentation to the completed
FBA.
Existing vs. New Data:
Were observations and interviews conducted
within 90 school days prior to the FBA
initiation date and was that information gathered
for the current inappropriate behavior?
 If yes, the data is considered “existing”
data.
 If no, those particular assessments must be
conducted as part of the FBA and are
considered “new” data.
INAPPROPRIATE BEHAVIOR:
REQUIRED SOURCES OF INFORMATION
Education history/testing
Attendance history
Discipline records
Medical/medication history
Diagnostic evaluations
Previous FBA, PBIP, or interventions
1. Records Review
2. Interview with Parent or Guardian
Existing or
Date Completed:
Interviewee:
Date Completed:
Interviewee:
Date Completed:
Observer:
New
3. Interview with Teacher or Staff
Existing or
Intervention data/graphs
IEP
Classroom logs/notes
Developmental/Social History
Other:
New
4. Functional Assessment Observation #1
(ABC Data or Scatterplot Data)
Existing or
New
Location:
Functional Assessment Observation #2
(ABC Data or Scatterplot Data)
Existing or
New
*One observation must be from someone
outside of the classroom.
5. Baseline Data on Inappropriate Behavior
Existing or
New
Date Completed:
Observer:
Location:
A minimum of 3 to 5 days of data must be collected to calculate the
baseline average. This data must be entered on the FBA form.
WERE ALL OF THE REQUIRED SOURCES OF INFORMATION COLLECTED?
YES
NO
If NO, indicate the reason why the information was not collected.
The student was not available for direct observation.
The student’s behavior was a one-time serious incident.
The parent does not consent to the collection of additional data (see bottom of next page).
Other:
EVS-016 – Revised: 07/10
FBA Planning Form – Page 1 of 2
FBA PLANNING FORM
-Sources of InformationOPTIONAL SOURCES OF INFORMATION
Interview with:
Existing or
New
Date Completed:
Interview with:
Existing or
New
Date Completed:
Existing or
New
Date Completed:
Existing or
New
Date Completed:
Existing or
New
Date Completed:
Existing or
New
Date Completed:
Existing or
New
Date Completed:
Other:
Existing or
New
Date Completed:
Other:
Existing or
New
Date Completed:
Behavior Rating Scale or Questionnaire
Social Skills Checklist
Setting Events Checklist
Classroom Management Checklist
Reinforcer Assessment or Checklist
PARENTAL CONSENT
Is the FBA for a student with a disability or to assist in determining ESE services for a student?
YES
NO
If NO, consent is not needed. If any new data is needed to complete the FBA, determine data gathering procedures,
assign responsibilities, and set deadlines. Once all information is gathered, schedule the team meeting to complete the
FBA form and possibly develop a PBIP.
If YES, was “new” checked for any of the sources above?
YES
NO
If NO, consent is not needed.
If YES, PARENTAL CONSENT must be obtained prior to collecting the information. Refer to the procedures
below. Once consent is obtained, determine data gathering procedures, assign responsibilities, and set deadlines. Once
all information is gathered, schedule the team meeting to complete the FBA form and possibly develop a PBIP.
ESE Students with Disabilities
If an FBA is being completed for a student with a
disability or a student with a 504 plan, it is considered a
re-evaluation and parental consent must be obtained. In
these cases, parental consent is obtained by using the
“Informed Notice and Consent for Re-evaluation” form.
EVS-016 – Revised: 07/10
General Education Students
If an FBA is being completed for a student who is not
identified with a disability, an FBA would only require
parental consent if it is being completed to assist in
determining ESE services for that student. In these cases,
parental consent is obtained on the “001 Referral Form.”
FBA Planning Form – Page 2 of 2
The School District of Escambia County
FUNCTIONAL BEHAVIORAL ASSESSMENT
Name:
Student ID#:
School:
Grade:
Date of FBA Meeting:
Gender:
DOB:
Age:
Check One:
ESE
GEN
If ESE, list exceptionalities:
STEP 1: IDENTIFY THE PROBLEM BEHAVIOR
For what reason(s) was the Functional Behavioral Assessment (FBA) initiated? Check all that apply.
*If initiated for a one-time serious offense, complete the FBA (One-time Serious Offense) Form instead.
The student’s behavior consistently disrupts the learning environment.
The student’s behavior is not consistently disruptive, but requires proactive interventions to prevent further
escalation.
The student’s behavior places the student or others at risk of harm and/or results in substantial property damage.
Behavioral concerns are resulting in exclusion from participation in activities or settings with peers.
The educational team is considering a more restrictive placement due to behavioral concerns.
Current intervention involves excessively intrusive procedures (e.g., secured seclusion, therapeutic hold).
The student’s behavior persists despite behavior management strategies that were previously implemented
consistently.
Other:
Briefly summarize a history of the student’s inappropriate behaviors that prompted this FBA.
Identify ONE inappropriate behavior to be addressed for intervention. Define the behavior by using specific terms that
ensure the behavior can be easily observed and recorded by all parties involved.
INAPPROPRIATE BEHAVIOR:
BEHAVIOR DEFINITION:
EVS-015 – Revised: 07/10
Functional Behavior Assessment – Page 1 of 5
Distribution: Cumulative Folder, Teacher(s), Parent, Central Files (if ESE)
STUDENT NAME:
DATE:
STEP 2: GATHER SOURCES OF INFORMATION
REQUIRED SOURCES: At a minimum, the FBA sources of information should at least include the sources below.
Documentation of all sources should be recorded on the FBA Planning (Sources of Information) form and then
attached to the FBA.
 Records review
 2 functional assessment observations (one observation
must be from someone outside the classroom)
 Structured interview with the parent or guardian

Baseline data
 Structured interview with a teacher or school
personnel
BASELINE DATA
Check the type of data collected on the inappropriate behavior.
Frequency (total #)
Rate (freq ÷ time)
% of Intervals (e.g., 15 min, 30 min) 
Average Duration
% of Activities
Behavior Rating Scale
minutes
Other:
Enter the baseline data into the table below and calculate the baseline average. A minimum of 3 to 5 days of data must
be collected to calculate the baseline average.
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10 Average
STEP 3: SUMMARIZE ASSESSMENT DATA
STRENGTHS/SKILLS: What are the student’s strengths? When is the student most successful (e.g., academically,
behaviorally, socially)?
SETTING EVENTS: What events or conditions affect how the student responds to situations? Check all that apply.
The following are examples of possible setting events. Setting events can be environmental, physiological, social, or
related to learning and self-regulation.
Change in teacher
Change in living environment
Crowded conditions
Noisy environment
Curricular issues
Insufficient sleep
Hunger/Thirst
Skill Deficit:
Medical condition:
Change/Missed medication
Side effects of medication
Pain
Illness
Atypical sensory needs
Depression
Previous arguments
Difficulty with peer(s)
Stress from home/community
Vision
Hearing
Anxiety
Death of family member
Loss or Failure
Comments/Other:
EVS-015 – Revised: 07/10
Functional Behavior Assessment – Page 2 of 5
Distribution: Cumulative Folder, Teacher(s), Parent, Central Files (if ESE)
STUDENT NAME:
DATE:
ANTECEDENTS: What is most likely to “trigger” or immediately precede the inappropriate behavior?
Check all that apply in relation to the inappropriate behavior being assessed.
Morning, Approximate time(s):
When is the
inappropriate behavior
most likely to occur?
Where does the
inappropriate behavior
usually occur?
During what subject area
or activity is the
inappropriate behavior
most likely to occur?
Who is present when the
inappropriate behavior
usually occurs?
Are there any EVENTS
or CONDITIONS that
immediately precede the
inappropriate behavior?
Afternoon, Approximate time(s):
Before school
After school
Recess
Lunch
Time of day does not seem to affect this
behavior
Other:
Classroom
Cafeteria
Bus
Hallway
Playground/Recess
Bathroom
Gym
Therapy:
Unstructured setting
Special(s):
Location does not seem to affect this
behavior
Other:
Subject(s)
Seatwork/Independent work
Group activities
Unstructured activities
Transitions
Free play
1:1 instruction
Lesson presentation
Task explanations
Subject/Activity does not seem to affect
this behavior
Other:
Teacher
Other staff
Classmates
Other peers
Therapist:
Who is present does not seem to affect this
behavior
Other:
Demand or request to student
Non-preferred/difficult task
Non-preferred activity
Non-preferred social interaction
Transition from a preferred to nonpreferred activity
Lack of attention or attention is
given to others
Changes in schedule or routine
Loss of privilege
Consequences imposed for behavior
Preferred activity/item interrupted or
terminated
Denied access to a preferred item or
activity
Touch/Physical contact with the student
A particular sound, sight, etc.
Request was denied/Told “no”
Reprimand was given
Comments or teasing from other students
(provocation from peers)
Other:
Comments/Other:
EVS-015 – Revised: 07/10
Functional Behavior Assessment – Page 3 of 5
Distribution: Cumulative Folder, Teacher(s), Parent, Central Files (if ESE)
STUDENT NAME:
DATE:
CONSEQUENCES: What is most likely to immediately follow the occurrence of the inappropriate behavior?
Check all that apply in relation to the inappropriate behavior being assessed.
Verbal reprimand/Corrective
feedback from teacher/adult
Laughing/comments/teasing from
peers
Scared or shocked reaction from
others
Eye contact
Soothing/calming interaction
from teacher/adult
Student is given access to a
preferred activity/item
Student is given time to relax and
calm down
Removal from the setting
Removal to a different area of the
room
Another student is moved away
Assignment is shortened or
terminated
Student does not complete work
or activity
Loss of privileges
Loss of time with a preferred
person or activity
Loss of points (reward/incentive
system)
In-class time-out
Out-of-class time-out
Secured Seclusion
Therapeutic hold
Sensory stimulation
Behavior is ignored
Law enforcement/legal
involvement
Comments/Other:
PREVIOUS INTERVENTIONS: What has been consistently implemented to change the inappropriate behavior?
Check all that apply in relation to the inappropriate behavior being assessed.
In-class time-out
Out-of-class time-out
Time in office
Loss of privileges
Conference with student
Conference/contact with parents
Detention
In-school suspension
Out-of-school suspension
Environmental modifications
Reward/Point systems
Curriculum modifications
Modified instruction
Schedule adjustment
Setting limits (expectations,
rules, and consequences)
Home/school communication
system
Behavior or academic contract
Verbal reprimands/corrections
Redirection techniques
Referral to Guidance or
Intervention Specialist
Counseling by:
Emergency Procedures:
Comments/Other:
PREFERENCES & REINFORCERS: What school-related items and activities are most enjoyable to the student?
Are there special items, activities, privileges, or social interactions that could serve as special rewards for appropriate
behavior (e.g., praise, hug, stickers, line leader, breaks from work, computer time, homework pass, positive notes
home, candy, etc.)
EVS-015 – Revised: 07/10
Functional Behavior Assessment – Page 4 of 5
Distribution: Cumulative Folder, Teacher(s), Parent, Central Files (if ESE)
STUDENT NAME:
DATE:
STEP 4: FORMULATE SUMMARY STATEMENTS
FUNCTION: After reviewing the data on antecedents
and consequences, what “payoff” does the student
obtain when she/he demonstrates the inappropriate
behavior?
Check only what applies. Limit to 1 or 2 functions.
The student GAINS….
Teacher/adult attention
Peer attention/acceptance
Desired items
Preferred activities/privileges
Control over others or situations
Sensory stimulation (input)
HYPOTHESIS: Based on the primary function identified,
write a hypothesis statement describing why the student is
engaging in the inappropriate behavior.
Example: When working on independent seatwork during his
regular education math class, this student breaks his pencils and
throws them in order to escape work that is too difficult.
WHEN (describe antecedents)….
…THE STUDENT (describe inappropriate behavior)…
The student AVOIDS or ESCAPES…
Teacher/adult attention
Peer attention
Non-preferred activity
Instructional task (difficult, boring, repetitive, etc.)
Non-preferred setting
Non-preferred social interaction
A transition
Aversive physical sensations
Sensory stimulation (reduction)
…IN ORDER TO (state the function)…
DEFICIT: Is the student’s failure to perform an appropriate alternative behavior due primarily to a:
Skill Deficit (the student does not know how to perform the appropriate behavior/skill)
Performance Deficit (the student is capable of performing an appropriate behavior/skill but chooses not to do so)
PARTICIPANTS SIGNATURES:
____________________________
Parent
Date
_____________________________
LEA Representative
Date
______________________________
General Education Teacher
Date
____________________________
Student
Date
_____________________________
ESE Teacher
Date
______________________________
Other/Title
Date
____________________________
Other/Title
Date
_____________________________
Other/Title
Date
______________________________
Other/Title
Date
EVS-015 – Revised: 07/10
Functional Behavior Assessment – Page 5 of 5
Distribution: Cumulative Folder, Teacher(s), Parent, Central Files (if ESE)