FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA)

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					July 2010 (Paper Copy)                                                                           FBA-Page 1 of 2 for Preschool and School Age
                                                                 New Hanover County Schools
                                                            Functional Behavioral Assessment (FBA)

Name_______________________________                       Review Student’s Strengths:                             Review Target Behavior: (See PBIS 4)

ID# ________________________________                      ___________________________________                     ______________________________________
Date of Birth_________________________                    ___________________________________                     ______________________________________
Meeting Date_________________________                     ___________________________________                     ______________________________________

A                  Antecedents                           B                  Behavior                      C                Consequences
        Check factors noted prior to target behavior.    Summarize behavior at each level of intensity    Check events that typically follow the target behavior.
                                                         from the data gathered during the last 2 weeks
                                                         on the Frequency Data Sheet. Be specific, and
                                                         look for patterns.
   Physical / medical (discomfort / change in           Mild:                                               Internal / intrinsic pleasure
    meds?)                                                                                                    _____________________________________
    __________________________________                                                                       Teacher / adult attention
   Social / emotional (with whom / negative                                                                  _____________________________________
    interaction / social skill deficit?)                                                                     Peer attention
    __________________________________                                                                        _____________________________________
   Communication (understand instructions /                                                                 Verbal warning / reprimand
    make needs known?)                                                                                        _____________________________________
    __________________________________                   Moderate:                                           Loss of privilege (what kind? school? home?)
   Environmental / classroom (over-stimulated /                                                              _____________________________________
    noisy / crowded?)                                                                                        Time out (where? how long?)
    __________________________________                                                                        _____________________________________
   Academic / instructional (too easy / too difficult                                                       Detention (how long? what kind?) (include #)
    / not interested / unorganized / large group /                                                            _____________________________________
    independent work?)                                                                                       Removal from class (bounced) (include #)
    __________________________________                                                                        _____________________________________
    __________________________________                   Severe:                                             Office referral (include #)
   Setting events (response to command /                                                                     _____________________________________
    transition / unstructured / change in routine/ bus                                                       Restitution (what kind?)
    / time / person / subject?)                                                                               _____________________________________
    __________________________________                                                                       In school suspension (how long?)
    __________________________________                                                                        _____________________________________
   Home (change in home / family dynamics?)                                                                 Out of school suspension (how long?)
    __________________________________                                                                        _____________________________________
   Other _________________________________                                                                  Legal charges (what kind?)
    ___________________________________                                                                       _____________________________________
    ___________________________________                                                                      Bus referrals/suspensions (include #)
    ___________________________________                                                                       _____________________________________
    ___________________________________                                                                      Other ________________________________
                                                                                                       FBA-Page 2 of 2 for Preschool and School Age
                                                                                                         Name: ______________________________
                                                                                                         ID #: ______________________________


                           Function of Target Behavior                                                              Hypothesis
                    What does the student gain from this behavior?                              What variables appear to trigger this behavior?
                                                                                                     What does the behavior look like?
                                                                                                  What seems to reinforce this behavior?

   Attention from:                                                                    Example:
     Peers       ____________________________________________________                    When Johnnie is in small group instruction and/or gym
                                                                                          (SETTING) and does not get his way (ANTECEDENT /
                                                                                          CONTEXT), he typically responds by shoving and/or using
       Staff       ____________________________________________________
                                                                                          threatening language (BEHAVIOR) to gain attention
                                                                                          (FUNCTION).
       Preferred adult ________________________________________________
                                                                                       Fill in the blanks to complete your hypothesis:

   Power:                                                                             When student is _____________________________________
      Control      ___________________________________________________                                              (SETTING)
                                                                                       and _______________________________________________
       Intimidation __________________________________________________                                    (ANTECEDENT / CONTEXT)
                                                                                       he/she typically responds by
                                                                                       __________________________________________________
       Vengeance __________________________________________________
                                                                                                                    (BEHAVIOR)
                                                                                       to gain ____________________________________________
                                                                                                                    (FUNCTION)
   Escape / avoidance of:
     Activity or task _______________________________________________                 If this is a specific/one time incident that is being considered for long-
                                                                                       term suspension, then describe the incident.
       Particular person _______________________________________________

       Classroom        _______________________________________________


   Self-stimulation to reduce :
     Anxiety _____________________________________________________
       Fear     _____________________________________________________



                                      For a list of meeting participants, see SST/IAP Attendance Log or IEP Page 1.

				
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