Functional Behavioral Assessment (FBA)

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					                    I. Functional Behavioral Assessment (FBA) Worksheet

Article 7: Sec. 41. “Functional behavioral assessment” means a process that uses data to identify patterns in the
student's behavior and the purpose or function of the behavior for the student. A functional behavioral assessment
may require written parental consent if it is an educational evaluation as defined in section 30 of this rule. Written
parental consent is not required when a functional behavioral assessment reviews existing data regarding a student,
as specified in 511 IAC 7-40-3(b)(3). (Indiana State Board of Education; 511 IAC 7-32-41)

Student:                                 School:                                   Date:

                                         #1                           #2                             #3
1. Target Behavior:



Frequency:

Duration

Intensity:

2. Antecedents

Location(s):



Time(s):


Subject(s)/
Activities:


Persons
Involved:



Other
antecedent(s):



3. Consequence(s):




4. Perceived
  Function(s):
                 Functional Behavioral Assessment (FBA) - continued


                              #4                  #5                  #6
1. Target Behavior:



Frequency:

Duration

Intensity:

2. Antecedents

Location(s):



Time(s):



Subject(s)/
Activities:



Person(s)
Involved:



Other
antecedent(s):


3. Consequence(s):




4. Perceived
  Function(s):
5. Setting events: Are there specific conditions, events or activities that make each
problem behavior worse? (e.g. medical conditions, missed medications, medication side effects,
history of academic failure, conflict at home, missed meals, lack of sleep, history of problems with peers)
Think of setting events as things that “set up” problem behavior, and antecedents as things that “set off”
problem behavior.




6. Propose hypotheses by summarizing Setting Event and A-B-C patterns.

     Setting Event           Antecedent                   Behavior                    Consequence

                                                          1.


                                                          2.


                                                          3.


                                                          4.


                                                          5.


                                                          6.
7. Replacement behavior(s). For each target behavior, identify an appropriate, existing behavior
that can replace the problem behavior or propose a new replacement behavior that can be taught to the
student as part of the behavioral intervention plan.

Behavior in repertoire (need to reinforce use) :            New behavior to teach (establish and reinforce):

1.                                                   1.

2.                                                   2.

3.                                                   3.

4.                                                   4.

5.                                                   5.

6.                                                   6.

8. Reinforcement and student strengths. List 5-10 reinforcers and student strengths
that can be incorporated into the behavioral intervention plan.

Student reinforcers:                                             Student strengths:
Student:                               School:                                Date:

                       II. Behavioral Intervention Plan (511 IAC 7-32-10)
           (a.)    “Behavioral intervention plan” means a plan, agreed upon by the case conference
                   committee and incorporated into a student’s IEP that describes the following: (1) The
                   pattern of behavior that impedes the student’s learning or the learning of others; (2)
                   The purpose or function of the behavior as identified in a functional behavioral
                   assessment; (3) The positive interventions and supports, and other strategies, to: (A)
                   address the behavior; and (B) maximize consistency of implementation across people
                   and settings in which the student is involved; and (4) If applicable, the skills that will
                   be taught and monitored in an effort to change a specific pattern of behavior of the
                   student. The behavioral intervention plan seeks to maximize consistency of
                   implementation across people and settings in which the student is involved.
           (b.)    The IEP can serve as the behavioral intervention plan as long as the documentation
                   the parent receives meets all the requirements in this section.

       Goals of Behavioral Intervention:
         
         
         
         
         

For each hypothesis developed from the FBA, describe how staff will attempt to: (a) prevent its
occurrence; (b) teach and reinforce replacement behavior(s) that serve the same function as the problem
behavior, and (c) respond to problem behavior when it does occur in a manner that prevents the problem
behavior from being reinforced and decreases the likelihood of escalation.

                                      Hypothesis for Problem Behavior

 A. When this occurs… (describe the    B. The student does… (describe the        C. In order to… (describe the
 circumstances)                        behavior)                                 function)




    Prevention of this behavior        Alternative/replacement behaviors to      Responding to the behavior
                                       teach and reinforce
                                     Hypothesis for Problem Behavior

A. When this occurs… (describe the     B. The student does… (describe the     C. In order to… (describe the
circumstances)                         behavior)                              function)




Prevention of this behavior            Alternative/replacement behaviors to   Responding to the behavior
                                       teach and reinforce




                                     Hypothesis for Problem Behavior

A. When this occurs… (describe the     B. The student does… (describe the     C. In order to… (describe the
circumstances)                         behavior)                              function)




                                       Alternative/replacement behaviors to   Responding to the behavior
Prevention of this behavior            teach and reinforce
                                     Hypothesis for Problem Behavior

A. When this occurs… (describe the     B. The student does… (describe the     C. In order to… (describe the
circumstances)                         behavior)                              function)




Prevention of this behavior            Alternative/replacement behaviors to   Responding to the behavior
                                       teach and reinforce




                                     Hypothesis for Problem Behavior

A. When this occurs… (describe the     B. The student does… (describe the     C. In order to… (describe the
circumstances)                         behavior)                              function)




Prevention of this behavior            Alternative/replacement behaviors to   Responding to the behavior
                                       teach and reinforce
 Crisis Management: (outline procedures to protect the student, classmates and staff should
the student’s behavior escalate.)


Monitoring and Evaluation


                                           Monitoring Plan


                Types of            Data Collection                Timelines                   Implementer
                Outcomes            How will it be measured?   When and how often will it     Who is responsible for
                                                                    be measured?            monitoring implementation
               What will the team
                                                                                             and training relevant staff
                  measure?
                                                                                            about the intervention plan?
Decreases
                                                                                            Monitoring:
in problem
behavior
will result
in…
                                                                                            Training:
Increases in
replacement
skills will
result in…

Other

				
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