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Functional Behavior Assessment _FBA_

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					                                   Functional Behavioral Assessment (FBA)
                                           used by Johnson County Schools
                 Functional Behavioral Assessment is a systematic collection and analysis of data that will vary in
                                length and scope depending on the severity of a student’s behavior.
                         Results and analysis of the data collection are used in developing the student’s
                             Behavioral Intervention Plan which is discussed in the ISTART7 report.
                                         A Functional Behavioral Assessment will identify
                  patterns in the student’s behavior and the purpose or function of the behavior for the student.

          Student:                                                DOB:                Completed on:
          School:                                                 Grade:              Teacher:
          Form Completed by:

                      Participants in FBA development                              Date     Data Collection Method*
  Administrator
  Parent/Guardian
  Educator and Title
  Educator and Title
  Educator and Title
  Educator and Title
  Educator and Title
  Educator and Title
  Counselor
  Student
  Other
  Other
  Other
  Other
*Data Collection Methods: (1) Interview, (2) Form or Survey, (3) Observation, (4) Systematic Data Collection,
                          (5) Discipline/Incident Record, (6) Other – What?
Indicate the behavior(s) that impede his or her learning or the learning of others.
                                                          Categories:
                           Aggression                    Inappropriate              Noncompliance                       Off-Task                 Self-Injurious             Other
                                                             Talk
            Hitting                                     Talking out             Failing to comply with staff   Out-of-seat                   Head banging                Unresponsive
                                                                                requests or instructions
            Biting                                      Talking back to staff                                  Gesturing to peers            Using objects to cut or     Withdrawn
                                                                                Refusing to follow school                                    puncture self
            Spitting                                    Negative comments       rules, specifically:           Touching others                                           Socially
                                                                                ____________________                                         Pinching self               isolated
            Pushing                                     Using profanity                                        Talking to peers
                                                                                ____________________                                         Consuming inedible          Hygiene
            Scratching                                  Name calling                                           Appearing to be doing         substances                  issues
                                                                                Failing to begin task when     nothing
            Kicking                                     Yelling                 requested                                                    Vomiting                    Communica-
                                                                                                               Working on unrelated                                      tion problems
            Shoving                                     Making                  Refusing to talk               materials                     Pulling own hair
                                                        inappropriate sounds                                                                                             Other:
Behaviors




            Pulling hair                                                        Verbal refusals                Looking around room           Sucking/biting/scratching   ___________
                                                        Verbal threats                                                                       body parts
            Inappropriate touching                                              Arriving tardy to class        Putting head down in
                                                        Inappropriate                                          class/sleeping                Possession/use of
            Vandalism                                   symbolism               Truancy (class or day)                                       drugs/alcohol/inhalants/
                                                        (i.e., gang related)                                   Using objects to gain peer    tobacco
            Threatening others                                                  Hiding in the school           attention
                                                        Humming or singing      bldg./classroom                                              Other: _______________
            Hitting objects against desk, wall, floor                                                          Not attending to directions
                                                        Off-subject             Leaving class
            Tantruming                                  comments                                               Unprepared for class
                                                                                Leaving building
            Fighting                                    Harassing statements                                   Self-stimulating behaviors,
                                                                                Other: ________________        specifically:
            Bullying                                    Sexual innuendoes                                      __________________

            Destroying school objects such as           Other:                                                 __________________
            paper, pencil, books, assignments           ____________
                                                                                                               Other: ________________
            Other:
                              Prioritize the Categories or Behaviors indicated above which most interfere with the student’s learning.
                                         It is recommended that no more than three target behaviors be addressed in a BIP.

             1. _________________________________                        2. _________________________________                 3. _________________________________
                                                                                                                                                                                    2
Copy pages 3 and 4 for each identified target behavior.

 COMPLETE THE REST OF THIS FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA) BASED UPON THE TARGET BEHAVIOR:

                                _________________________________________________________________.


DATA COLLECTION: (Choose one) ATTACH DATA * Required.

       Frequency of behavior:                                     Intensity of behavior:                            Duration of behavior:

 __ daily      ___ # (behavior count)    ___ mild (disruptive but not dangerous)                                      __ seconds ________
                                         ___ moderate (verbal/physical threats and/or destructive to physical         __ minutes ________
 __ weekly     ___ # (behavior count)                  environment)                                                   __ hours __________
                                         ___ severe (poses a physical danger to student and/or other)
 __ monthly    ___ # (behavior count)


What is the function of the behavior? What need is being met by the behavior? (See FBA Resource Guide for suggestions of possible
functions and tools for determining the function of the target behavior). * Also insert into ISTART7, if developing an IEP.

_____________________________________________________________________________________________________________________________

HYPOTHESIS
(Team may identify 1 or 2 functions of the identified interfering behavior): *Also insert into ISTART7, if developing an IEP.


 When ___________________________________________________________________ ________________________________
                                      (identify setting events)                                         (student)
 will ____________________________________________________ at an approximate rate of _____________________________
                (behavior)                                                                (data collection baseline)
 in order to _________________________________________.
                     (purpose/function of behavior)


FUNCTIONALLY EQUIVALENT REPLACEMENT BEHAVIOR (F.E.R.B.):
                                                                                                                                        3
When situated in ____________________setting _________________________will __________________________ in order to
                    (situational factor)           (student)                        (F.E.R.B.)

__________________________________________________.
           (purpose/function of behavior)


ANNUAL GOAL - Designed to Address Behavior Skill Development: *Also insert into ISTART7 if developing an IEP.




Data regarding the Annual Goal will be gathered and recorded by __________________________________ every ____________________.
                                                                         person responsible                   how often

POSITIVE STRATEGIES/INSTRUCTIONAL EXPERIENCES: *Also insert into ISTART7 if developing an IEP.




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