FBA Worksheet

7/26/2019 FBA Worksheet

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Student Name (DOB) _________________________________________ Grade ________

Todays Date _________

School Di str ict/Bui lding __________________________________________________________

FBA Team Members

_____________________________________________________

_____________________________________________________

I ndirect Di rect

___ Record Review ___ Consultant Observation___ Behavior Logs/ Discipline Reports ___ ABC Data Collection

___ Structured Interviews w/__________________ ___ Staff Direct Observation___ Reports from ___________________________ ___ Other Direct DataCollection_____________

Rating Scales ___________________________

Tasks for completing an FBA Who? By when?

1. Obtain parental permission (if

applicable)2. Records Review

Academic

Medical

Discipline (SWIS)

3. Schedule/ conduct interviews(teachers/ staff)

4. Schedule / conduct interviewswith student and parents (ifnecessary)

5. Schedule / conduct observation

ABC Scatter plot

6. Summarize data and develophypothesis statement

7. Develop Behavior Support Plan

8. Evaluate Plan.

Functional Behavioral Assessment Worksheet


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Functional Behavioral Assessment

Student-Assisted Interview Form

Interviewer:___ ________ Date___________

Respondent__

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]?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

________________________


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Functional Behavioral Assessment

Teacher Interview FormInterviewer(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?

__________________________________________________________________________________________

__________________________________________________________________________________________


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__________________________________________________________________________________________

____________________________________________________________________________

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?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________


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Functional Assessment Checklist for Teachers and Staff (FACTS-Part A)

Student/ Grade: ______________________________ Date: ____________________________

Student Profile:Please identify at least three strengths or contributions the student brings to school.

___________________________________________________________________________________

___________________________________________________________________________________

Problem Behavior(s): Identify problem behaviors

___ Tardy ___ Fight/physical Aggression ___ Disruptive ___ Theft

___ Unresponsive ___ Inappropriate Language ___ Insubordination ___ Vandalism

___ Withdrawn ___ 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.

Schedule

(Times)

Activity Likelihood of Problem Behavior Specific Problem Behavior

Low High

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

1 2 3 4 5 6

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.

March, Horner, Lewis-Palmer, Brown , Crone, Todd & Carr (2000) 4/24/00

Step 1

Step 2

Step 3

Step 4

Step 5


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Functional Assessment Checklist for Teachers & Staff (FACTS-Part B)

Student/ Grade: ______________________________ Date: ____________________________

Interviewer: _________________________________ 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):

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)?

What are the events that predict when the problem behavior(s) will occur? (Predictors)

Related Issues (setting events)

Environmental Features

___ illness Other:_________________

___ drug use ______________________

___ negative social ______________________

___ conflict at home ______________________

___ academic failure ______________________

___ reprimand/correction ___ structured activity

___physical demands ___ unstructured time

___ socially isolated ___ tasks too boring

___ with peers ___ activity too long

___ Other ___ tasks too difficult

__________________

What consequences appear most likely to maintain the problem behavior(s)?

Things that are Obtained

Things Avoided or Escaped From

___ adult attention Other: ________________

___ peer attention ______________________

___ preferred activity ______________________

___ money/things ______________________

___ 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

1

Step2

Step

3

Step

4

Step

5

Step

6


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How confident are you that the Summary of Behavior is accurate?

Not very confident Very Confident1 2 3 4 5 6

What current efforts have been used to control the problem behavior?

Strategies for preventing problem behavior

Strategies for responding to problembehavior

___ schedule change Other: ________________

___ seating change ______________________

___ curriculum change ______________________

___ reprimand Other: ___________________

___ office referral _________________________

___ detention _________________________

March, Horner, Lewis-Palmer, Brown , Crone, Todd, & Carr (2000) 4/24/00

ep 7

ep 8


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The Functional Assessment Checklist for Teachers and Staff (FACTS):

Instructions

The FACTS is a two-page interview used by school personnel who are building behaviorsupport 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 studentbest, and used to either build behavior support plans, or guide more complete functional assessmentefforts. 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 Profi le

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: I denti fy 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 briefdescription 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 students 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).


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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 Fur ther 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 asroutines 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: I denti fy 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 multipleroutines 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 thisroutine?


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Step #5: I denti fy the Consequences that M ay Maintain the Problem Behavior

What consequences appear to reward the problem behavior? Consider that the student mayget/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 theconsequence 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 problembehavior later in the escalation.

Step #6: Bui ld 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 andFACTS-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 confidentthat 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 occurtogether

Step #8: Define what has been done to date to prevent/contr ol 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 gettingstarted, (b) those things that were delivered as consequences to control or punish the problem behavior(or reward alternative behavior).


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ABC OBSERVATION FORM

Student Name: _______________ Observation Date:________

Observer: __________________ Time: _________________

Activity: ___________________ Class Period: ____________

ANTECEDENT BEHAVIOR CONSEQUENCE


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Student: _____________________ Observer: ______________________

Date: ______________ Time: ___________ Activity: _______________

_______________________________________________________________

Context of Incident:

Antecedent:

Behavior:

Consequence:

Comments/Other Observations:


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Student Name: Ben S._______ Observation Date: 10/5____

Observer: R. Day____________ Time: 9:40-9:55 a.m.______

Activity: disruptive behavior____ Class Period: 3__________


Teacher beginstells 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 andpokes Fran with pencil.

Teacher tells Ben, get to work,NOW!

Ben calls out, this is too

hard. He throws

worksheet and book onfloor.

Teacher demands that Ben come

forward, get a hall pass, and go to

the office.


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APPENDIX B


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_________


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 tome!

Girls throw ball to her, shemisses it and another girl,

LuAnne catches it and throwsit 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 behindKaren and kicks her

saying Give it to me

damn it!

Karen cries. Trish takesthe ball.


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APEX II Functional Behavioral Assessment

FUNCTIONAL ASSESSMENT SCATTERPLOT

Student: _______________________________ Grade: ________ School:

______________________________

Date(s): _______________________________Observer(s):_________________________________________

Behavior(s) of concern:________________________________________________________________________

ACTIVITY TIME DAY OFTHE WEEK

TOTAL

Monday Tuesday Wednesday Thursday Friday

TOTAL


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FUNCTIONAL ASSESSMENT SCATTERPLOT

Student: Myree Grade: 6th School: John B.

Lynn

Date(s): 10/4/97 to 10/8/97 Observer(s): Dennis

Behavior(s) of concern: disrupts class w/inappropri ate comments and verbal threats directed at peers.

Setting:__________________________________________________________________________________

ACTIVITY TIME

DAY OF

THE WEEK TOTAL

Monday Tuesday Wednesday Thursday FridayMATH 9:20-

10:10II IIII III II IIII 15

SCIENCE 10:10-11:00

I II I I II 7

SOCIAL

STUDIES11:00-11:50

II IIII IIII I IIII 15

TOTAL 5 10 8 4 10


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PROBLEM BEHAVIOR QUESTIONNAIRE

Student ____________________________ Teacher _______________________ Date ________________

Student Behavior: Keeping in mind the problem behaviors identified in the Teacher I nterview. Circle the frequency

at which each of the following statements is true.Never 10% of 25% of 50% of 75% of 90% of Always

time time time time time1. 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 youredirect the student to get back to task orfollow the rules? 0 1 2 3 4 5 6

3. During a conflict with peers, if the studentengages in the problem behavior, do peersleave the student alone? 0 1 2 3 4 5 6

4. When the problem behavior occurs, do peersverbally 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 yourattention when you are working with another

student? 0 1 2 3 4 5 6

7. Does the problem behavior occur in thepresence of specific peers? 0 1 2 3 4 5 6

8. Is the problem behavior more likely to continueto occur throughout the day following an earlierepisode? 0 1 2 3 4 5 6

9. Does the problem behavior occur during specificacademic activities? 0 1 2 3 4 5 6

10. Does the problem behavior stop when peersstop 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 anacademic 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 occurfollowing unscheduled events or disruption inclassroom routines? 0 1 2 3 4 5 6


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Student _____________________

Problem Behavior Questionnai re Prof il ePeers Peers Adults Adults Setting Events

Escape Attention Escape Attention______________________

Question:

3 10 14 4 7 11 1 9 13 2 6 12 5 8 15

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Developed by Lewis, Timothy J., Scott, Terrance M., Sugai, George. (1994) Diagnostic,

19 (2-3), 1-3-115.


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FINAL REPORT

STUDENT ASSISTANCE TEAM

XY HIGHSCHOOL

FUNCTIONAL ASSESSMENT OF BEHAVIOR

DATE:

NAME: SCHOOL:BIRTH DATE GRADE:

AGE: TEACHER:

PRIMARY LANGUAGE: EVALUATOR

REASON FOR REFERRAL

Namewas referred to the evaluator by REFERRAL SOURCE. It is our hope that thisevaluation 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/heracademic 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:

I ndirect Direct

___ Record Review ___ Consultant Observation___ Behavior Logs/ Discipline Reports ___ ABC Data Collection

___ Structured Interviews w/__________________ ___ Staff Direct Observation

___ Reports from ___________________________ ___ Other Direct Data Collection________________ Rating Scales ___________________________ ___________________________________

Name is anage-year-old, grade-grade-sex who attends School. She/He has attended School

since Month, Year. School attendance has been attendance pattern.


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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 tohave 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) Nameappears to obtain (List whatthe behavior gets for the student). and/or Specifically, because of (Behavior problem)

Nameappears to escape or avoid (Report what the behavior allows the student

Hypothesized Function of the Target BehaviorBased on this, what FUNCTION might the behavior be serving?(What is the student GETTING or AVOIDING by engaging inthe behavior)

INTERNAL EXTERNAL

ACCESS / GET

Something

___ Cognitive ________________________

___ Emotional _______________________

___ Communication

___ Control ___ Revenge

___ Sensory

___Auditory ___Visual

___ OTHER ___________________________

___ Attention _________________________

___ Tangibles

___ Activities _________________________

___ Other ____________________________

AVOID/ESCAPE

Something

___ Cognitive _________________________

___ Emotional ________________________

___ Physiological ______________________

___ Sensory

___Auditory ___Visual

___ OTHER ___________________________

___ Setting __________________________

___ Task _____________________________

___ Activity __________________________

___ Person(s) _________________________

___ Academic Subject __________________

___ 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.


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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 students 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 Nameor 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 (Statebeginning 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).


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ESTABLISHING OPERATIONS THAT MAY INFLUENCE BEHAVIOR (SETTING EVENTS)

Also referred to as setting events or ecological variables, these events typically occur themorning 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 eventswere 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 students environment CONSISTENT (i.e: similar expectations, directions,discipline strategies. Please describe)

_______________________________________________________

Are the adults in the students environment RESPECTFUL of the students

values/needs?________________________________________

Additional ANTECEDENTS / SETTING EVENTS Checklist (check/describe most relevant

contextual variables)

Medical/Emoti

onal

EnvironmentalSocial/

Interactional

Curricular/

Instructional Personal

___

Hunger/Thirst

___ Auditory ___ Social

Expectations

___ Task Difficulty ___Choice-

Making

___ Restroom ___ Visual ___ Opportunity ___ Task Length ___Communica


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w/ peers tion

___ Health ___ Transition ___ Teacher /

Staff

___ Rate of Presentation ___Emotional

___ Medication ___

Predictability

___ Proximity ___ Delivery of

Instruction

___Routine

Dependent

___ Diet ___ Class Size ___ Behavior ofPeers ___ Level of Assistance ___PersonalLikes/Dislikes___ Sleep ___ Seating ___ Necessary

Social Skills

___ Meaningful ___Coping

Skills

___ Clothing ___ Change ofStaff

___ Variation of Material

DESCRIBE:

______________________________________________________________________________

__________________________________________________________________

________________________________________________________________________


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Behavior Support Plan,

Summary Statement of the Problem

Behavior Pathway

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 ortriggers of the behavior appear to include (List Antecedents). The immediate consequences of

Names behavior problem typically include (Consequences). Given this result of his/her

behavior it is suggested that the problem behavior is negatively and/or positivelyreinforcing.In other words, when Nameengages in (Target Behavior) he/sheis likely to obtain (Positive

Reinforcers) and/orescape and/oravoid (Negative Reinforcers).

Setting event

Alternative Behavior

Problem Behavior

Desired Behavior

Maintaining consequences

FunctionMaintaining

consequences


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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 programrecommendations are offered:

(Positive alternative behaviors)

List strategies that make the problem behaviors irrelevant, ineffective, & inefficient

Predictor (setting event)

Strategies (how to modify thesetti ng events)

e.g: Does not understand

work.

Instructional Strategies

e.g:

1. Pre teach work at

beginning of class ifthere is availabletime.

2. Teacher report to

Mentor or GuidanceCounselor regularly

on homework

completion.

Consequence Strategies

1.Take a moment

after/before class tothank Johnny fordoing work.

2. Be sure to thank

Johnny if he asks forhelp with work.

Behavior Modifications(replace problem behavior s)

e.g: Blows up at teacher

1. Say to Johnny, your

behavior right now is

inappropriate. Thengive him the option to

either take walk to thedrink fountain and

return within 2

minutes (If you are

not back by then, youwill be reported to the

office) or to calm

down and return to his

seat.

2.

If refuses tocooperate, follow

standard classroomdiscipline procedure

for expressed

behavior.

1. If Johnny speaks

with the teacher after

class, thank him fortaking the time to

calm down andspeak about the

matter.

2. If Johnny goes aweek resolving

disputes with

teachers in a

reasonable manner,

then notifyMentor/Guidance to

reward him withdrink/snack.


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QUALITYOFLIFEINTERVENTIONS

The following interventions are geared towards improving the students 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________________________

Check

M T W Th

F M T W Th

F M T W Th

F M T W Th

F M T W Th

F High

Risk

For

Mon

th

Tardy

Skip

Absent

Behavi

or

Referr

alDetent

ion

In

school

suspen

sion

Out of

school

suspen

sion

Failing

Classes /

behin

d in

Credit

s

_____ Ds ____Fs _____Classes Passed out of ______ Total. _____Credits earned out of _____

Total

ect BasicShared general info


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Provided regular feedback

Discussed staying in school

Problem solved about risk

IntensiveArranged 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:


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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


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Behavior Support Plan ReviewStudent ____________________________________ Grade ____________

School _____________________________________ Date _____________

SAT monitoring member____________________________________

1. Review each task on the BSP Implementation plan to identify whether all tasks are being

implemented successfullyanswer below under

REVIEW DATA

MODIFICATIONS TO THE BSP IMPLEMENTATION PLANTasks Person Responsible By

When

Was task

Completed

consistently?

Evaluation

Decision

Monitor, Modify, orDiscontinue

Date & Time of the Next BSP Review meeting ________________________________

__________________________________ _______________________________Parent/Guardian SAT member

_

_________________________________ _______________________________Other staff member General Education Teacher

Data Collected

Scatter-plot, point card, etc.Summary of the data

# of occurrences/ patterns/ pointsearned out of possible points)

Evaluation Decision

Goal Attained/ Reinforcement Earned

Is Plan Being

Implemented?

Is Plan Making a

Difference?

Documents

FBA Worksheet