FUNCTIONAL BEHAVIOR ASSESSMENT
FUNCTIONAL BEHAVIOR ASSESSMENT
Student________________________________SS#______________________
Grade____________Teacher_____________________DOB______________
School____________________________Today’s Date___________________
Person completing form________________________Position___________
Current Service________________________________Hours/Week______
Certification_________________________Date of Last Eval.____________
Relevant medical information:
Relevant social history:
Student communicates by:
List student’s strengths and weaknesses:
Academic:
Social:
Describe the problem behavior(s):
Frequency and duration of problem behavior(s):
When and where does the problem behavior(s) occur?
_________With a certain person? Who?________________________
_________Certain area of the school? Specify__________________
_________Certain time of the day? (e.g. subject, lunch, recess, hall, bathroom) Specify____________________________________________
_________Certain activity? (e.g. whole vs. small group, seatwork, transition) Specify__________________________________________
_________In response to direct request or instruction
_________In response to reprimand
_________When left alone
_________When ignored
_________When denied certain activity/privilege
_________When routine is changed unexpectedly
Other:
Describe what actually happened (the consequences) as a result of the problem behavior(s):
As a result of the problem behavior(s), the student:
Got: Avoided:
__________Attention __________Difficult task
__________Activity/Tangible __________Teacher/Adult demand
__________Sensory Stimulation __________Certain activity/person
Academic skills that need to be addressed in order for this student to be successful include:
Members of Assessment Team Position
_____________________________ _______________________
_____________________________ _______________________
_____________________________ _______________________
_____________________________ _______________________
_____________________________ _______________________
_____________________________ _______________________
_____________________________ _______________________
_____________________________ _______________________
Tennessee Department of Education, Division of Special Education
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