WORKSHEET FOR A FUNCTIONAL BEHAVIOR ASSESSMENT …



WORKSHEET FOR A FUNCTIONAL BEHAVIOR ASSESSMENT (FBA)

Name of Student: _____________________________________ Grade: _______

Strengths of Student (ex. Likes the computer, enjoys sports, curious, sense of humor, sociable, etc.):

Specific Behaviors: __ Talking out loud __ Argumentative __ Fidgets __ Late to class

Behaviors that negatively __ Out of seat __ Hits/Fights __ Disturbs others __ Won’t participate

impacts student or others. __ Impulsive __ Lies __ Steals/Cheats __ Destructive

__ Harasses others __ Self-mutilation __ Cusses __ Oppositional

__ Teases others __ Withdrawn

What are __ Other (describe behaviors):

they doing?

Slow Triggers: __ Stressors during the day __ Lack of coping skills

Ongoing events that the __ Parental/Sibling conflict __ Lack of academic skills

student lives with daily. __ Substance abuse __ Medical/Psychiatric diagnosis (i.e. ADHD, etc.)

__ Divorce/Parents separated __ Poor diet/sleep

__ Illness

__ Other (describe events):

Fast Triggers: __ Independent work __ Touched by others __ Transition

Events that occur __ Group instruction __ Peer encouragement __ Reprimanded

immediately before the __ Class activity __ Negative social interaction __ Corrected

problem behaviors. __ Unstructured activity __ Loud noise(s) __ Consequences

__ Difficult task __ Change in routine __ Teased

__ Requests by adults

What sets __ Other (describe events):

them off?

Consequences: __ Ignore __ Loss of privileges/incentives __ Send to office

Events that occur after __ Detention __ Communication w/ home __ Reprimand/Warning

the behaviors. __ Discussion __ Suspension

__ Other (describe events):

What do you

do about it?

Perceived Function: AVOID/ESCAPE: __ Work/activity/task __ Feeling inadequate

What purposes do these __ Interaction __ Change in routine/Transition

behaviors serve for the __ A request __ Reprimand/Correction

student? __ A person __ Physical discomfort

__ Other (describe):

Why do you

think they OBTAIN: __ Attention (adult/peer) __ Communication

are doing it? __ Specific activity/item __ Tension release (i.e. anger)

__ Revenge __ Power/Control

__ Other (describe):

Intensity: Impact on learning is: __ High __ Medium __ Low

Rewards: __ Praise __ Computer time __ Rewards at home __ Candy/Snack

What will the student work __ Free time __ Time with specific person/class

for? __ Other (describe):

What can

we do to

motivate?

Success of what has Successful:

been tried:

What have you done to try

to change these behaviors

and how have they worked?

Unsuccessful:

Additional Comments:

Completed by/Title: ________________________________ Date: ______________

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