Functional Behavioral Assessment Worksheet
Student Name (DOB) _________________________________________ Grade ________
Today’s Date _________
School District/Building __________________________________________________________
FBA Team Members
_____________________________________________________
_____________________________________________________
Indirect
___ Record Review
___ Behavior Logs/ Discipline Reports
___ Structured Interviews w/__________________
___ Reports from ___________________________
Collection_____________
Rating Scales ___________________________
Tasks for completing an FBA
1. Obtain parental permission (if
applicable)
2. Records Review
 Academic
 Medical
 Discipline (SWIS)
3. Schedule/ conduct interviews
(teachers/ staff)
4. Schedule / conduct interviews
with student and parents (if
necessary)
5. Schedule / conduct observation
 ABC
 Scatter plot
6. Summarize data and develop
hypothesis statement
7. Develop Behavior Support Plan
8. Evaluate Plan.
Who?
Direct
___ Consultant Observation
___ ABC Data Collection
___ Staff Direct Observation
___ Other Direct Data
By when?
Functional Behavioral Assessment
Student-Assisted Interview Form
Interviewer:___
Respondent__
________
Date___________
1. Tell me about things that you like/ dislike at school, home, and other places.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________
2. Tell me about things that seem to be going well or not so well at school, home, and other places.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________
3. Tell me about the subject or class you like most or least. Why?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________
4. Tell me about when you seem to have the most or least problems (where you are; what time of day; who
else is around you).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________
5. Tell me what happens when you [target behavior]. What does the teacher say or do. What do the other
students say or do?
______________________________________________________________________________
__________________________________________________________________________________________
____________________________
6. Do you remember what were you thinking right before you [target behavior]?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________
Functional Behavioral Assessment
Teacher Interview Form
Interviewer(s)_________________________________________Date(s)_______________________________
Student(s)_________________________________________________________________________________
Respondent(s)___________________________________________
1. Describe the behavior of Concern
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________________________________________________
2. How often does the behavior occur?
________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How long does it last?
__________________________________________________________________________________________
____________________________________________________________________________________
How intense is the behavior?
__________________________________________________________________________________________
______________________________________________________________________________
3. What is happening when the behavior occurs?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4. When/where is the behavior most/least likely to occur?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________
5. With whom is the behavior most/least likely to occur?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________
6. What conditions are most likely to precipitate (“set off ”) the behavior?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________
7. How can you tell the behavior is about to start?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________
8. What usually happens after the behavior? Describe what happens according to adult(s), peers, and
student
responses.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________
9. What is the likely function (intent) of the behavior; that is, why do you think the student behaves this
way?
What does the student get or avoid?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________________
10. What behavior(s) might serve the same function (see question 9) for the student that is appropriate
within the social/environmental context?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
11. What other information might contribute to creating an effective behavioral intervention plan (e.g.,
under what conditions does the behavior not occur?)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________________________________________________________
12. Who should be involved in the planning and implementation of the behavioral intervention plan?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________
Functional Assessment Checklist for Teachers and Staff (FACTS-Part A)
Step 1
Student/ Grade: ______________________________
Step 2
Student Profile: Please identify at least three strengths or contributions the student brings to school.
___________________________________________________________________________________
___________________________________________________________________________________
Step 3
Problem Behavior(s): Identify problem behaviors
Date: ____________________________
___ Tardy
___ Unresponsive
___ Withdrawn
___ Fight/physical Aggression ___ Disruptive
___ Theft
___ Inappropriate Language
___ Insubordination
___ Vandalism
___ Verbal Harassment
___ Work not done
___ Other ________________
___ Verbally Inappropriate
___ Self-injury
Describe problem behavior:
____________________________________________________________
Identifying Routines: Where, When and With Whom Problem Behaviors are Most Likely.
Step 4
Schedule
(Times)
Activity
Likelihood of Problem Behavior
Low
1
2
3
4
5
High
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
Specific Problem Behavior
Select 1-3 Routines for further assessment: Select routines based on (a) similarity of activities (conditions) with
ratings of 4, 5 or 6 and (b) similarity of problem behavior(s). Complete the FACTS-Part B for each routine
identified.
Step 5
March, Horner, Lewis-Palmer, Brown , Crone, Todd & Carr (2000)
4/24/00
Functional Assessment Checklist for Teachers & Staff (FACTS-Part B)
Step
1
Step
2
Student/ Grade: ______________________________
Interviewer: _________________________________
Date: ____________________________
Respondent(s): ____________________
Routine/Activities/Context: Which routine(only one) from the FACTS-Part A is assessed?
Routine/Activities/Context
Problem Behavior(s)
Provide more detail about the problem behavior(s):
Step
3
What does the problem behavior(s) look like?
How often does the problem behavior(s) occur?
How long does the problem behavior(s) last when it does occur?
What is the intensity/level of danger of the problem behavior(s)?
Step
4
What are the events that predict when the problem behavior(s) will occur? (Predictors)
Related Issues (setting events)
Environmental Features
___ illness
___ drug use
___ negative social
___ conflict at home
___ academic failure
Other:_________________
______________________
______________________
______________________
______________________
___ reprimand/correction
___ physical demands
___ socially isolated
___ with peers
___ Other
__________________
___ structured activity
___ unstructured time
___ tasks too boring
___ activity too long
___ tasks too difficult
What consequences appear most likely to maintain the problem behavior(s)?
Things that are Obtained
Step
5
Things Avoided or Escaped From
___ adult attention
___ peer attention
___ preferred activity
___ money/things
Other: ________________
______________________
______________________
______________________
___ hard tasks
Other: ___________________
___ reprimands
________________________
___ peer negatives ________________________
___ physical effort ________________________
___ adult attention ________________________
SUMMARY OF BEHAVIOR
Identify the summary that will be used to build a plan of behavior support.
Setting Events & Predictors
Problem Behavior(s)
Maintaining Consequence(s)
Step
6
Step 7
How confident are you that the Summary of Behavior is accurate?
Not very confident
1
Step 8
2
3
4
Very Confident
5
6
What current efforts have been used to control the problem behavior?
Strategies for preventing problem behavior
Strategies for responding to problem
behavior
___ schedule change
Other: ________________
___ seating change
______________________
___ curriculum change ______________________
March, Horner, Lewis-Palmer, Brown , Crone, Todd, & Carr (2000)
___ reprimand
Other: ___________________
___ office referral _________________________
___ detention
_________________________
4/24/00
The Functional Assessment Checklist for Teachers and Staff (FACTS):
Instructions
The FACTS is a two-page interview used by school personnel who are building behavior
support plans. The FACTS is intended to be an efficient strategy for initial functional behavioral
assessment. The FACTS is completed by people (teachers, family, clinicians) who know the student
best, and used to either build behavior support plans, or guide more complete functional assessment
efforts. The FACTS can be completed in a short period of time (5-15 min). Efficiency and
effectiveness in completing the forms increases with practice.
How to Complete the FACTS-Part A
Step #1: Complete Demographic Information:
Indicate the name and grade of the student, the date the assessment data were collected, the
name of the person completing the form (the interviewer), and the name(s) of the people providing
information (respondents).
Step #2: Complete Student Profile
Begin each assessment with a review of the positive, and contributing characteristics the
student brings to school. Identify at least three strengths or contributions the student offers.
Step #3: Identify Problem Behaviors
Identify the specific student behaviors that are barriers to effective education, disrupt the
education of others, interfere with social development or compromise safety at school. Provide a brief
description of exactly how the student engages in these behaviors. What makes his/her way of doing
these behaviors unique? Identify the most problematic behaviors, but also identify any problem
behaviors that occur regularly.
Step #4: Identify Where, When and With Whom the Problem Behaviors are Most Likely
A: List the times that define the student’s daily schedule. Include times between classes, lunch,
before school and adapt for complex schedule features (e.g. odd/even days) if appropriate.
B: For each time listed indicate the activity typically engaged in during that time (e.g. small
group instruction, math, independent art, transition).
C: Use the 1 to 6 scale to indicate (in general) which times/activities are most and least likely to
be associated with problem behaviors. A “1” indicates low likelihood of problems, and a “6” indicates
high likelihood of problem behaviors.
D: Indicate which problem behavior is most likely in any time/activity that is given a rating of
4, 5 or 6.
Step #5: Select Routines for Further Assessment
Examine each time/activity listed as 4, 5 or 6 in the Table from Step #4. If activities are similar
(e.g. activities that are unstructured; activities that involve high academic demands; activities with
teacher reprimands; activities with peer taunting) and have similar problem behaviors treat them as
“routines for future analysis”.
Select between 1 and 3 routines for further analysis. Write the name of the routine, and the
most common problem behavior(s). Within each routine identify the problem behavior(s) that are
most likely or most problematic.
For each routine identify in Step #5 complete a FACTS-Part B
How to Complete the FACTS-Part B
Step #1: Complete Demographic Information:
Identify the name and grade of the student, the date that the FACTS-Part B was completed,
who completed the form, and who provided information for completing the form.
Step #2: Identify the Target Routine
List the targeted routine and problem behavior from the bottom of the FACTS-Part A. The
FACTS-Part B provides information about ONE routine. Use multiple Part B forms if multiple
routines are identified.
Step #3: Provide Specifics about the Problem Behavior(s)
Provide more detail about the features of the problem behavior(s). Focus specifically on the
unique and distinguishing features, and the way the behavior(s) is disruptive or dangerous.
Step #4: Identify Events that Predict Occurrence of the Problem Behavior(s)
Within each routine what (a) setting events, and (b) immediate preceding events predict when
the problem behavior(s) will occur. What would you do to make the problem behaviors happen in this
routine?
Step #5: Identify the Consequences that May Maintain the Problem Behavior
What consequences appear to reward the problem behavior? Consider that the student may
get/obtain something they want, or that they may escape/avoid something they find unpleasant.
Identify the most powerful maintaining consequence with a “1”, and other possible
consequences with a “2” or “3.” Do not check more than three options. The focus here, is on the
consequence that has the greatest impact.
When problems involve minor events that escalate into very difficult events, separate the
consequences that maintain the minor problem behavior from the events that may maintain problem
behavior later in the escalation.
Step #6: Build a Summary Statement
The summary statement indicates the setting events, immediate predictors, problem behaviors,
and maintaining consequences. The summary statement is the foundation for building an effective
behavior support plan. Build the summary statement from the information in the FACTS-A and
FACTS-B (Especially the information in Steps #3, #4, and #5 of the FACTS-B). If you are confident
that the summary statement is accurate enough to design a plan move into plan development. If you
are less confident, then continue the functional assessment by conducting direct observation.
Procedures for completing the functional assessment, and for designing behavioral support are
described in the following references.
Step #7: Determine “Level of Confidence”
Use the 1-6 scale to define the extent to which you, the interviewer or the team are “confident”
that the summary statement is accurate. Confidence may be affected by factors such as (a) how often
the problem behavior occurs, (b) how long you have known the focus person, (c) how consistent the
problem behaviors are, (d) if multiple functions are identified, and (e) if multiple behaviors occur
together
Step #8: Define what has been done to date to prevent/control the problem behavior
In most cases, school personnel will have tried some strategies already. List events that have
been tried, and organize these by (a) those things that have been to prevent the problem from getting
started, (b) those things that were delivered as consequences to control or punish the problem behavior
(or reward alternative behavior).
ABC OBSERVATION FORM
Student Name: _______________
Observation Date:________
Observer: __________________
Time: _________________
Activity: ___________________
Class Period: ____________
ANTECEDENT
BEHAVIOR
CONSEQUENCE
ABC OBSERVATION FORM
Student: _____________________
Observer: ______________________
Date: ______________ Time: ___________ Activity: _______________
_______________________________________________________________
Context of Incident:
Antecedent:
Behavior:
Consequence:
Comments/Other Observations:
ABC OBSERVATION FORM
Student Name:
Ben S._______
Observation Date: 10/5____
Observer:
R. Day____________
Time: 9:40-9:55 a.m.______
Activity:
disruptive behavior____
Class Period: 3__________
ANTECEDENT
BEHAVIOR
CONSEQUENCE
Teacher begins – tells students to look at
board.
Ben looks around room
and at other kids.
Teacher continues lesson; ignores
Ben.
Teacher puts examples on board and asks
class to work problems.
Ben looks around and calls
to Fran.
Teacher asks for quiet.
Teacher tells class to do 5 more problems.
Ben turns around and
pokes Fran with pencil.
Teacher tells Ben, “get to work,
NOW!”
Ben calls out, “this is too
hard.” He throws
worksheet and book on
floor.
Teacher demands that Ben come
forward, get a hall pass, and go to
the office.
APPENDIX B
ABC OBSERVATION FORM
Student Name: Trish________________
Observation Date: 10/5__
Observer: Ms. Pasillas________________
Time: 9:40-9:55 a.m.____
Activity: disruptive behavior on the playground
Class Period: 3_________
ANTECEDENT
BEHAVIOR
CONSEQUENCE
Trish joins group of 4 girls playing catch.
Trish waits for ball to be
thrown to her.
Girls do not throw ball to Trish.
Trish yells “Throw it to
me!”
Girls throw ball to her, she
misses it and another girl,
LuAnne catches it and throws
it to Sandy.
Ball is again thrown to Karen.
Trish yells “ I said throw
it to me you jerk!”
Karen begins to walk away with the ball.
Trish runs up behind
Karen and kicks her
saying “Give it to me
damn it!”
Karen cries. Trish takes
the ball.
FUNCTIONAL ASSESSMENT SCATTERPLOT
Student: _______________________________ Grade: ________ School:
______________________________
Date(s): _______________________________
Observer(s):_________________________________________
Behavior(s) of concern:
________________________________________________________________________
ACTIVITY
TIME
Monday
Tuesday
DAY OF
THE WEEK
Wednesday
TOTAL
APEX II Functional Behavioral Assessment
TOTAL
Thursday
Friday
FUNCTIONAL ASSESSMENT SCATTERPLOT
Grade: 6th
Student: Myree
Lynn
Date(s): 10/4/97 to 10/8/97
Observer(s):
School: John B.
Dennis
Behavior(s) of concern: disrupts class w/inappropriate comments and verbal threats directed at peers.
Setting:
__________________________________________________________________________________
ACTIVITY
TIME
MATH
9:2010:10
10:1011:00
11:0011:50
SCIENCE
SOCIAL
STUDIES
TOTAL
DAY OF
THE WEEK
Wednesday
TOTAL
Monday
Tuesday
Thursday
Friday
II
IIII
III
II
IIII
15
I
II
I
I
II
7
II
IIII
IIII
I
IIII
15
5
10
8
4
10
APEX II Functional Behavioral Assessment
PROBLEM BEHAVIOR QUESTIONNAIRE
Student ____________________________ Teacher _______________________
Date ________________
Student Behavior: Keeping in mind the problem behaviors identified in the Teacher Interview. Circle the frequency
at which each of the following statements is true.
Never
10% of
time
25% of
time
50% of
time
75% of
time
90% of
time
Always
1. Does the problem behavior occur and persist
when you make a request to perform a task?
0
1
2
3
4
5
6
2. When the problem behavior occurs, do you
redirect the student to get back to task or
follow the rules?
0
1
2
3
4
5
6
3. During a conflict with peers, if the student
engages in the problem behavior, do peers
leave the student alone?
0
1
2
3
4
5
6
4. When the problem behavior occurs, do peers
verbally respond or laugh at the student?
0
1
2
3
4
5
6
5. Is the problem behavior more likely to occur
following a conflict outside the classroom?
(e.g. bus write-up)
0
1
2
3
4
5
6
6. Does the problem behavior occur to get your
attention when you are working with another
student?
0
1
2
3
4
5
6
7. Does the problem behavior occur in the
presence of specific peers?
0
1
2
3
4
5
6
8. Is the problem behavior more likely to continue
to occur throughout the day following an earlier
episode?
0
1
2
3
4
5
6
9. Does the problem behavior occur during specific
academic activities?
0
1
2
3
4
5
6
10. Does the problem behavior stop when peers
stop interacting with the student?
0
1
2
3
4
5
6
11. Does the behavior occur when peers are
attending to other students?
0
1
2
3
4
5
6
12. If the student engages in the problem behavior,
do you provided one-to-one instruction to get
the student back on task?
0
1
2
3
4
5
6
13. Will the student stop doing the problem
behavior if you stop making requests or end an
academic activity?
0
1
2
3
4
5
6
14. If the student engages in the problem behavior,
do peers stop interacting with the student?
0
1
2
3
4
5
6
15. Is the problem behavior more likely to occur
following unscheduled events or disruption in
classroom routines?
0
1
2
3
4
5
6
APEX II Functional Behavioral Assessment
Student _____________________
Problem Behavior Questionnaire Profile
Peers
Escape
Question:
3
10
6
6
5
5
4
4
3
3
2
2
1
1
0
0
Peers
Attention
14
6
5
4
3
2
1
0
4
6
5
4
3
2
1
0
7
6
5
4
3
2
1
0
Adults
Escape
11
6
5
4
3
2
1
0
1
6
5
4
3
2
1
0
9
6
5
4
3
2
1
0
Adults
Setting Events
Attention______________________
13
6
5
4
3
2
1
0
2
6
5
4
3
2
1
0
6
6
5
4
3
2
1
0
12
6
5
4
3
2
1
0
5
6
5
4
3
2
1
0
8
6
5
4
3
2
1
0
15
6
5
4
3
2
1
0
Developed by Lewis, Timothy J., Scott, Terrance M., Sugai, George. (1994) Diagnostic,
19 (2-3), 1-3-115.
APEX II Functional Behavioral Assessment
FINAL REPORT
STUDENT ASSISTANCE TEAM
XY HIGHSCHOOL
FUNCTIONAL ASSESSMENT OF BEHAVIOR
DATE:
NAME:
BIRTH DATE
AGE:
PRIMARY LANGUAGE:
SCHOOL:
GRADE:
TEACHER:
EVALUATOR
REASON FOR REFERRAL
Name was referred to the evaluator by REFERRAL SOURCE. It is our hope that this
evaluation will aid in determining the function of the following behavior problem: PROBLEM
BEHAVIOR AS DEFINED BY REFERRAL SOURCE. From this assessment, a behavior
intervention plan will be developed.
These behaviors have interfered with Name's achievement of his/her academic goals and have
resulted in suspension/ failure from school. From this assessment a behavior intervention
program will be developed by the SAT.
At the time of referral Name displayed the following behaviors:
(list behaviors as identified by the referral source)


ASSESSMENT PROCEDURES
BACKGROUND INFORMATION
Data Collection Methods Used:
Indirect
Direct
___ Record Review
___ Behavior Logs/ Discipline Reports
___ Structured Interviews w/__________________
___ Reports from ___________________________
___ Rating Scales ___________________________
___ Consultant Observation
___ ABC Data Collection
___ Staff Direct Observation
___ Other Direct Data Collection_____________
___________________________________
Name is an age-year-old, grade-grade-sex who attends School. She/He has attended School
since Month, Year. School attendance has been attendance pattern.
APEX II Functional Behavioral Assessment
Behavioral History
From interviews (with) and record review it was learned that this behavior problem has
previously been displayed. (Describe history of behavior problem).
Previous interventions attempted to help manage this behavior problem have included the
following: (Describe prior interventions). The following intervention components appear to
have some potential and should be considered when developing Name's behavior intervention
plan: (Describe previously attempted interventions that were helpful). Alternatively, the
following components appear do not appear to have been helpful and should be avoided:
(Describe previously attempted interventions that were not helpful and should be avoided).
From this behavioral history a tentative hypothesis of the function(s) of the problem behavior
was (were) developed. It would appear that this behavior is positively- and/or negatively
reinforcing. Specifically, because of (Behavior problem) Name appears to obtain (List what
the behavior gets for the student). and/or Specifically, because of (Behavior problem)
Name appears to escape or avoid (Report what the behavior allows the student
Hypothesized Function of the Target Behavior
Based on this, what FUNCTION might the behavior be serving? (What is the student GETTING or AVOIDING by engaging in
the behavior)
INTERNAL
ACCESS / GET
Something
AVOID/ESCAPE
Something
EXTERNAL
___ Cognitive ________________________
___ Emotional _______________________
___ Communication
___ Control
___ Revenge
___ Sensory
___Auditory ___Visual
___ OTHER ___________________________
___ Attention _________________________
___ Cognitive _________________________
___ Emotional ________________________
___ Physiological ______________________
___ Sensory
___Auditory ___Visual
___ OTHER ___________________________
___ Setting __________________________
___ Task _____________________________
___ Activity __________________________
___ Person(s) _________________________
___ Academic Subject __________________
___ OTHER
___________________________
___ Tangibles
___ Activities _________________________
___ Other ____________________________
Replacement Behaviors
From interviews (with) it was determined that (State incompatible behavior) was a positive
alternative behavior incompatible with the target behavior. Specifically, (Provide a clear
behavioral description of the replacement behavior). This behavior would appear to obtain
the same goal as the target behavior.
APEX II Functional Behavioral Assessment
PROBLEM IDENTIFICATION:
Describe the BEHAVIOR(s) of concern (observable and measurable):
_1.______________________________________________________________________________________________
_2.______________________________________________________________________________________________
_3.______________________________________________________________________________________________
Consequences of the Replacement Behavior
Currently, consequences of Name's (Replacement behavior) include (List the result or
consequence of the replacement behavior for the student).
Potential reinforcers for the replacement behavior may include (From hypothesized function of
behavior, list possible reinforcers that may increase the replacement behavior).
Consequences Maintaining the Behavior/FUNCTION:
What events typically FOLLOW the behavior? (See ABC Data)
_____________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Behavior Intensity (How severe is the behavior?)
This data helps to document the severity of the target behavior. At the time of this assessment,
the behavior was rated as being a Level ? (On a scale of 1 to 5, with 5 being the most severe) on
a disruptive behavior rating rubric. This level of behavioral severity is defined as follows:
Level 1, Behavior is confined only to the observed student.
Level 2, Behavior disrupts others in the student’s immediate area.
Level 3, Behavior disrupts everyone in the class.
Level 4, Behavior disrupts other classrooms or common areas of the school.
Level 5, Behavior causes or threatens to cause physical injury to Name or others.
Behavior Duration (How long does the behavior last?)
Duration data reflects the time that the behavior was expressed from beginning to end. For the
purposes of baseline data collection, the behavior was judged to begin when Name (State
beginning criteria) and to end when (State ending criteria). Data from each of the (state # of
days) baseline data days was as follows:
Date
Duration
During the data collection period Name displayed the behavior for a total (Total amount of
time). On average the behavior lasted (Average).
APEX II Functional Behavioral Assessment
ESTABLISHING OPERATIONS THAT MAY INFLUENCE BEHAVIOR (SETTING EVENTS)
Also referred to as setting events or ecological variables, these events typically occur the
morning of or evening before a given behavior is displayed. They make it more or less likely
that a behavior will be judged as reinforcing (e.g., a student who is hungry will, find behaviors
that obtain food more reinforcing). They also influence the likelihood that a behavior will occur
(e.g., a student who is tired is more likely to display task avoidance behaviors). These events
were identified by rating scales, observation, interview, and/or record review.
Antecedent / Setting Events (Contextual Variables):
What conditions tend to “SET OFF” the behavior (look for patterns in ABC Data)?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
For whom is the behavior a problem? _________________________
For whom is the behavior NOT a problem? ____________________
Where does the behavior occur MOST often? ________________________________
LEAST often? _______________________________
At what time of the day does the behavior occur MOST often?
______________________LEAST often? ___________________________
During what activities does the behavior occur MOST often?________________________ Least
often?___________________________
Are the expectations for this student REASONABLE (describe)?
_____________________________________________________________
Are the adults in the student’s environment CONSISTENT (i.e: similar expectations, directions,
discipline strategies. Please describe)
_______________________________________________________
Are the adults in the student’s environment RESPECTFUL of the student’s
values/needs?________________________________________
Additional ANTECEDENTS / SETTING EVENTS Checklist (check/describe most relevant
contextual variables)
Medical/Emoti
onal
___
Hunger/Thirst
___ Restroom
Environmental
Social/
___ Auditory
___ Visual
Interactional
___ Social
Expectations
___ Opportunity
Curricular/
Instructional
___ Task Difficulty
___ Task Length
APEX II Functional Behavioral Assessment
Personal
___ChoiceMaking
___Communica
___ Health
___ Transition
___ Medication
___ Diet
___
Predictability
___ Class Size
___ Sleep
___ Seating
___ Clothing
w/ peers
___ Teacher /
Staff
___ Proximity
___ Behavior of
Peers
___ Necessary
Social Skills
___ Change of
Staff
___ Rate of Presentation
___ Delivery of
Instruction
___ Level of Assistance
___ Meaningful
tion
___Emotional
___Routine
Dependent
___Personal
Likes/Dislikes
___Coping
Skills
___ Variation of Material
DESCRIBE:
______________________________________________________________________________
__________________________________________________________________
________________________________________________________________________
APEX II Functional Behavioral Assessment
Behavior Support Plan,
Summary Statement of the Problem
Behavior Pathway
Maintaining consequences
Alternative Behavior
Setting event
Problem Behavior
Maintaining
consequences
Function
D esired Behavior
SUMMARY
This assessment was designed to help determine the function of the following serious behavior
problem: (Target Behavior). From this assessment it has been determined that the following
events are establishing operations for this behavior: (List events). Immediate antecedents or
triggers of the behavior appear to include (List Antecedents). The immediate consequences of
Name’s behavior problem typically include (Consequences). Given this result of his/her
behavior it is suggested that the problem behavior is negatively and/or positively reinforcing.
In other words, when Name engages in (Target Behavior) he/she is likely to obtain (Positive
Reinforcers) and/or escape and/or avoid (Negative Reinforcers).
APEX II Functional Behavioral Assessment
RECOMMENDATIONS
(Try to avoid combining recommendations. Be specific in each recommendation. Use scripting for teachers when
necessary. They should allow individuals not familiar with the student, the classroom, or even your assessment data
to implement what you recommend)
From this functional assessment of behavior the following behavior intervention program
recommendations are offered:
(Positive alternative behaviors)
List strategies that make the problem behaviors irrelevant, ineffective, & inefficient
Predictor (setting event)
Strategies (how to modify the
setting events)
e.g: Does not understand
work.
Behavior Modifications
(replace problem behaviors)
e.g: Blows up at teacher
Instructional Strategies
e.g:
1. Pre teach work at
beginning of class if
there is available
time.
2. Teacher report to
Mentor or Guidance
Counselor regularly
on homework
completion.
1. Say to Johnny, your
behavior right now is
inappropriate. Then
give him the option to
either take walk to the
drink fountain and
return within 2
minutes (If you are
not back by then, you
will be reported to the
office) or to calm
down and return to his
seat.
2. If refuses to
cooperate, follow
standard classroom
discipline procedure
for expressed
behavior.
APEX II Functional Behavioral Assessment
Consequence Strategies
1.Take a moment
after/before class to
thank Johnny for
doing work.
2. Be sure to thank
Johnny if he asks for
help with work.
1. If Johnny speaks
with the teacher after
class, thank him for
taking the time to
calm down and
speak about the
matter.
2. If Johnny goes a
week resolving
disputes with
teachers in a
reasonable manner,
then notify
Mentor/Guidance to
reward him with
drink/snack.
Connect
QUALITY OF LIFE INTERVENTIONS
The following interventions are geared towards improving the student’s life outside school in his
natural settings at home and social events. These types of interventions will ensure that NAME
will have a consistent reinforcement pattern across the board.
Personal Modifications: (modifications the student can do at home and /or social settings in
order to achieve the desired goals/ desired behaviors)
Check & Connect Monitoring Sheet
Month_______________ Student_____________________
ID_____________________
School_____________________________________
Monitor________________________
Chec
k
M T
W T
h
F
M T W T
h
F
M T
W T
h
F
M T
W T
h
F
M T
W T
h
Tardy
Skip
Absent
Behavi
or
Referr
al
Detent
ion
In
school
suspen
sion
Out of
school
suspen
sion
Failing
Classe
s/
behin
d in
Credit
s
_____ D’s
Total
____F’s _____Classes Passed out of ______ Total.
_____Credits earned out of _____
Basic
Shared general info
APEX II Functional Behavioral Assessment
F
Hig
h
Risk
For
Mon
th
Provided regular feedback
Discussed staying in school
Problem solved about risk
Intensive
Arranged for alternative to
suspension
Contracted for behavior or
grades
Communicated with parents
Made special
accommodations
Participated in Community
Service
Participated in school
sponsored activity
Participated in social skills
group
Worked with tutor or
mentor
Other:
APEX II Functional Behavioral Assessment
Family modification: (modifications that parents can do at home in order to achieve the desired
goals/ desired behaviors)
__________________________________ _______________________________
Parent/Guardian
SAT member
_________________________________
Other staff member involved
_______________________________
General Education Teacher
_________________________________
Student
APEX II Functional Behavioral Assessment
Behavior Support Plan Review
Student ____________________________________ Grade ____________
School _____________________________________ Date _____________
SAT monitoring member____________________________________
1. Review each task on the BSP Implementation plan to identify whether all tasks are being
implemented successfully – answer below under
REVIEW DATA
Data Collected
Scatter-plot, point card, etc.
Summary of the data
# of occurrences/ patterns/ points
earned out of possible points)
Evaluation Decision
Goal Attained/ Reinforcement Earned
Is Plan Being
Implemented?
Is Plan Making a
Difference?
MODIFICATIONS TO THE BSP IMPLEMENTATION PLAN
Tasks
Person Responsible
By
When
Was task
Completed
consistently?
Evaluation
Decision
Monitor, Modify, or
Discontinue
Date & Time of the Next BSP Review meeting ________________________________
__________________________________ _______________________________
Parent/Guardian
SAT member
_
_________________________________
_______________________________
Other staff member
General Education Teacher
APEX II Functional Behavioral Assessment