Fba Template FUNCTIONAL BEHAVIOR ASSESSMENT FBA Student’s Name Primary Disability Grade Date

							                   FUNCTIONAL BEHAVIOR ASSESSMENT (FBA)

Student’s Name                                           Primary Disability
Grade                                                    Date of Birth
School
Date of Report
Staff involved in the FBA       1)   special education teacher
                                2)   adult support workers (paraprofessional)
                                3)   general education staff
                                4)   administration
                                5)   parent
                                6)   other
Instruments used                                                        Date
                                                                     completed
                                                                        Date
                                                                     completed
                                                                        Date
                                                                     completed
                                                                        Date
                                                                     completed
                                                                        Date
                                                                     completed

This document is a guide to components that should be addressed when completing an FBA.
Please make the appropriate changes to make this individualized to the student’s needs.
Anything in italics and the watermark can be removed from this template.

A functional behavior assessment was completed utilizing a variety of strategies including
observations, interviews and a review of records. The following is a summary of the results of this
assessment:

   1) Reason for the Functional Behavior Assessment (FBA)

   2) Strengths of the student:

   3) Medical information: (Documentation that the team has considered or other treatable causes
      for the target behaviors, including mental or physical health condition)

   4) Major life stressors: (Include major changes in home, loss of family member, friend, pet, and
      any other “stressors” the student has experienced in the past 1-2 years.)

   5) Target Behaviors: (complete a section for each target behavior the team wants to address or
      focus on)
      Target Behavior #1
          1) Definition – (Describe the target behavior specifically with frequency, severity and
             duration)

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            2) Environment – (A description of the environment and changes in which the target
               behaviors occur that may reduce the frequency of the behaviors.)
            3) Antecedents - (Antecedents that maintain the target behavior, along with events, times
               and situations that predict the occurrence and nonoccurrence of the target behaviors)
            4) Interventions – (Consequences [positive and negative] and other reinforcers that maintain
               the target behavior.)
                   a. (Also include a description of the positive behavioral interventions and supports
                       and other strategies used in the past and the effectiveness of each)

Target Behavior #2
         1) Definition – (Describe the target behavior specifically with frequency, severity and
             duration)
         2) Environment – (A description of the environment and changes in which the target
             behaviors occur that may reduce the frequency of the behaviors.)
         3) Antecedents - (Antecedents, that maintain the target behavior, along with events, times
             and situations that predict the occurrence and nonoccurrence of the target behaviors)
         4) Interventions – (Consequences [positive and negative] and other reinforcers that maintain
             the target behavior.)
                 a. (Also include a description of the positive behavioral interventions and supports
                     and other strategies used in the past and the effectiveness of each)

   6) Review of Records (i.e. incident reports, records of other placements)

   7)   Information Reported by the Student: (Use the FBA student interview & reinforcement survey)

   8) Information Reported by the Parent/Guardian: (Use the FBA parent interview)

   9) Information Reported by Staff: (Use the FBA teacher checklist, FBA interview form, and/or FBA teacher
        follow-up)

   10) Functions of Behavior (Use the Motivational Assessment Scale)

   11) Observations

   12) Replacement Behaviors and Needs – (Address for each target behavior)
          1) Positive reinforcements that can be used motivators
          2) Replacement Behaviors
          3) Needs
          4) Document whether regulated interventions are needed or not

   13) Summary




                                          Page 2 of 2                          Template Revision: December 2009