Functional Behavioral Assessment Worksheet

Student Name (DOB) _________________________________________ Grade ________

Todays Date _________
School District/Building __________________________________________________________
FBA Team Members
_____________________________________________________
_____________________________________________________
Indirect
___ Record Review
___ Behavior Logs/ Discipline Reports
___ Structured Interviews w/__________________
___ Reports from ___________________________
Collection_____________
Rating Scales ___________________________
Tasks for completing an FBA
1. Obtain parental permission (if
applicable)
2. Records Review
Academic
Medical
Discipline (SWIS)
3. Schedule/ conduct interviews
(teachers/ staff)
4. Schedule / conduct interviews
with student and parents (if
necessary)
5. Schedule / conduct observation
ABC
Scatter plot
6. Summarize data and develop
hypothesis statement
7. Develop Behavior Support Plan
8. Evaluate Plan.

Who?

Direct
___ Consultant Observation
___ ABC Data Collection
___ Staff Direct Observation
___ Other Direct Data

By when?

Functional Behavioral Assessment

Student-Assisted Interview Form

Interviewer:___
Respondent__

________

Date___________

1. Tell me about things that you like/ dislike at school, home, and other places.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________
2. Tell me about things that seem to be going well or not so well at school, home, and other places.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________
3. Tell me about the subject or class you like most or least. Why?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________
4. Tell me about when you seem to have the most or least problems (where you are; what time of day; who
else is around you).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________
5. Tell me what happens when you [target behavior]. What does the teacher say or do. What do the other
students say or do?
______________________________________________________________________________
__________________________________________________________________________________________
____________________________
6. Do you remember what were you thinking right before you [target behavior]?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________

Functional Behavioral Assessment

Teacher Interview Form
Interviewer(s)_________________________________________Date(s)_______________________________
Student(s)_________________________________________________________________________________
Respondent(s)___________________________________________
1. Describe the behavior of Concern
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________________________________________________
2. How often does the behavior occur?
________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How long does it last?
__________________________________________________________________________________________
____________________________________________________________________________________
How intense is the behavior?
__________________________________________________________________________________________
______________________________________________________________________________
3. What is happening when the behavior occurs?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4. When/where is the behavior most/least likely to occur?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________
5. With whom is the behavior most/least likely to occur?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________
6. What conditions are most likely to precipitate (set off ) the behavior?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________
7. How can you tell the behavior is about to start?
__________________________________________________________________________________________
__________________________________________________________________________________________

__________________________________________________________________________________________
____________________________________________________________________________
8. What usually happens after the behavior? Describe what happens according to adult(s), peers, and
student
responses.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________
9. What is the likely function (intent) of the behavior; that is, why do you think the student behaves this
way?
What does the student get or avoid?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________________
10. What behavior(s) might serve the same function (see question 9) for the student that is appropriate
within the social/environmental context?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
11. What other information might contribute to creating an effective behavioral intervention plan (e.g.,
under what conditions does the behavior not occur?)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________________________________________________________
12. Who should be involved in the planning and implementation of the behavioral intervention plan?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________

Functional Assessment Checklist for Teachers and Staff (FACTS-Part A)

Step 1

Student/ Grade: ______________________________

Step 2

Student Profile: Please identify at least three strengths or contributions the student brings to school.
___________________________________________________________________________________
___________________________________________________________________________________

Step 3

Problem Behavior(s): Identify problem behaviors

Date: ____________________________

___ Tardy
___ Unresponsive
___ Withdrawn

___ Fight/physical Aggression ___ Disruptive

___ Theft
___ Inappropriate Language
___ Insubordination
___ Vandalism
___ Verbal Harassment
___ Work not done
___ Other ________________
___ Verbally Inappropriate
___ Self-injury
Describe problem behavior:
____________________________________________________________

Identifying Routines: Where, When and With Whom Problem Behaviors are Most Likely.
Step 4

Schedule
(Times)

Activity

Likelihood of Problem Behavior

Low
1
2

High
6

Specific Problem Behavior

Select 1-3 Routines for further assessment: Select routines based on (a) similarity of activities (conditions) with
ratings of 4, 5 or 6 and (b) similarity of problem behavior(s). Complete the FACTS-Part B for each routine
identified.
Step 5

March, Horner, Lewis-Palmer, Brown , Crone, Todd & Carr (2000)

4/24/00

Functional Assessment Checklist for Teachers & Staff (FACTS-Part B)

Step
1

Step
2

Student/ Grade: ______________________________

Interviewer: _________________________________

Date: ____________________________
Respondent(s): ____________________

Routine/Activities/Context: Which routine(only one) from the FACTS-Part A is assessed?

Routine/Activities/Context
Problem Behavior(s)

Provide more detail about the problem behavior(s):

Step
3

What does the problem behavior(s) look like?

How often does the problem behavior(s) occur?
How long does the problem behavior(s) last when it does occur?
What is the intensity/level of danger of the problem behavior(s)?

Step
4

What are the events that predict when the problem behavior(s) will occur? (Predictors)
Related Issues (setting events)

Environmental Features
___ illness
___ drug use
___ negative social
___ conflict at home
___ academic failure

Other:_________________
______________________
______________________
______________________
______________________

___ reprimand/correction
___ physical demands
___ socially isolated
___ with peers
___ Other
__________________

___ structured activity

___ unstructured time
___ tasks too boring
___ activity too long
___ tasks too difficult

What consequences appear most likely to maintain the problem behavior(s)?

Things that are Obtained
Step
5

Things Avoided or Escaped From

___ adult attention
___ peer attention
___ preferred activity
___ money/things

Other: ________________
______________________
______________________
______________________

___ hard tasks

Other: ___________________
___ reprimands
________________________
___ peer negatives ________________________
___ physical effort ________________________
___ adult attention ________________________

SUMMARY OF BEHAVIOR
Identify the summary that will be used to build a plan of behavior support.
Setting Events & Predictors
Problem Behavior(s)
Maintaining Consequence(s)
Step
6

Step 7

How confident are you that the Summary of Behavior is accurate?

Not very confident
1

Step 8

Very Confident
5

What current efforts have been used to control the problem behavior?
Strategies for preventing problem behavior

Strategies for responding to problem

behavior
___ schedule change
Other: ________________
___ seating change
______________________
___ curriculum change ______________________
March, Horner, Lewis-Palmer, Brown , Crone, Todd, & Carr (2000)

___ reprimand
Other: ___________________
___ office referral _________________________
___ detention
_________________________
4/24/00

The Functional Assessment Checklist for Teachers and Staff (FACTS):

Instructions
The FACTS is a two-page interview used by school personnel who are building behavior
support plans. The FACTS is intended to be an efficient strategy for initial functional behavioral
assessment. The FACTS is completed by people (teachers, family, clinicians) who know the student
best, and used to either build behavior support plans, or guide more complete functional assessment
efforts. The FACTS can be completed in a short period of time (5-15 min). Efficiency and
effectiveness in completing the forms increases with practice.

How to Complete the FACTS-Part A

Step #1: Complete Demographic Information:

Indicate the name and grade of the student, the date the assessment data were collected, the
name of the person completing the form (the interviewer), and the name(s) of the people providing
information (respondents).

Step #2: Complete Student Profile

Begin each assessment with a review of the positive, and contributing characteristics the
student brings to school. Identify at least three strengths or contributions the student offers.

Step #3: Identify Problem Behaviors

Identify the specific student behaviors that are barriers to effective education, disrupt the
education of others, interfere with social development or compromise safety at school. Provide a brief
description of exactly how the student engages in these behaviors. What makes his/her way of doing
these behaviors unique? Identify the most problematic behaviors, but also identify any problem
behaviors that occur regularly.
Step #4: Identify Where, When and With Whom the Problem Behaviors are Most Likely

A: List the times that define the students daily schedule. Include times between classes, lunch,
before school and adapt for complex schedule features (e.g. odd/even days) if appropriate.
B: For each time listed indicate the activity typically engaged in during that time (e.g. small
group instruction, math, independent art, transition).

C: Use the 1 to 6 scale to indicate (in general) which times/activities are most and least likely to
be associated with problem behaviors. A 1 indicates low likelihood of problems, and a 6 indicates
high likelihood of problem behaviors.
D: Indicate which problem behavior is most likely in any time/activity that is given a rating of
4, 5 or 6.

Step #5: Select Routines for Further Assessment

Examine each time/activity listed as 4, 5 or 6 in the Table from Step #4. If activities are similar
(e.g. activities that are unstructured; activities that involve high academic demands; activities with
teacher reprimands; activities with peer taunting) and have similar problem behaviors treat them as
routines for future analysis.
Select between 1 and 3 routines for further analysis. Write the name of the routine, and the
most common problem behavior(s). Within each routine identify the problem behavior(s) that are
most likely or most problematic.
For each routine identify in Step #5 complete a FACTS-Part B

How to Complete the FACTS-Part B

Step #1: Complete Demographic Information:

Identify the name and grade of the student, the date that the FACTS-Part B was completed,
who completed the form, and who provided information for completing the form.

Step #2: Identify the Target Routine

List the targeted routine and problem behavior from the bottom of the FACTS-Part A. The
FACTS-Part B provides information about ONE routine. Use multiple Part B forms if multiple
routines are identified.
Step #3: Provide Specifics about the Problem Behavior(s)

Provide more detail about the features of the problem behavior(s). Focus specifically on the
unique and distinguishing features, and the way the behavior(s) is disruptive or dangerous.
Step #4: Identify Events that Predict Occurrence of the Problem Behavior(s)

Within each routine what (a) setting events, and (b) immediate preceding events predict when
the problem behavior(s) will occur. What would you do to make the problem behaviors happen in this
routine?

Step #5: Identify the Consequences that May Maintain the Problem Behavior
What consequences appear to reward the problem behavior? Consider that the student may
get/obtain something they want, or that they may escape/avoid something they find unpleasant.
Identify the most powerful maintaining consequence with a 1, and other possible
consequences with a 2 or 3. Do not check more than three options. The focus here, is on the
consequence that has the greatest impact.
When problems involve minor events that escalate into very difficult events, separate the
consequences that maintain the minor problem behavior from the events that may maintain problem
behavior later in the escalation.

Step #6: Build a Summary Statement

The summary statement indicates the setting events, immediate predictors, problem behaviors,
and maintaining consequences. The summary statement is the foundation for building an effective
behavior support plan. Build the summary statement from the information in the FACTS-A and
FACTS-B (Especially the information in Steps #3, #4, and #5 of the FACTS-B). If you are confident
that the summary statement is accurate enough to design a plan move into plan development. If you
are less confident, then continue the functional assessment by conducting direct observation.
Procedures for completing the functional assessment, and for designing behavioral support are
described in the following references.

Step #7: Determine Level of Confidence

Use the 1-6 scale to define the extent to which you, the interviewer or the team are confident
that the summary statement is accurate. Confidence may be affected by factors such as (a) how often
the problem behavior occurs, (b) how long you have known the focus person, (c) how consistent the
problem behaviors are, (d) if multiple functions are identified, and (e) if multiple behaviors occur
together

Step #8: Define what has been done to date to prevent/control the problem behavior
In most cases, school personnel will have tried some strategies already. List events that have
been tried, and organize these by (a) those things that have been to prevent the problem from getting
started, (b) those things that were delivered as consequences to control or punish the problem behavior
(or reward alternative behavior).

ABC OBSERVATION FORM

Student Name: _______________

Observation Date:________

Observer: __________________

Time: _________________

Activity: ___________________

Class Period: ____________

ANTECEDENT

BEHAVIOR

CONSEQUENCE

ABC OBSERVATION FORM

Student: _____________________

Observer: ______________________

Date: ______________ Time: ___________ Activity: _______________

_______________________________________________________________
Context of Incident:

Antecedent:

Behavior:

Consequence:

Comments/Other Observations:

ABC OBSERVATION FORM

Student Name:

Ben S._______

Observation Date: 10/5____

Observer:

R. Day____________

Time: 9:40-9:55 a.m.______

Activity:

disruptive behavior____

Class Period: 3__________

ANTECEDENT

BEHAVIOR

CONSEQUENCE

Teacher begins tells students to look at

board.

Ben looks around room

and at other kids.

Teacher continues lesson; ignores

Ben.

Teacher puts examples on board and asks

class to work problems.

Ben looks around and calls

to Fran.

Teacher asks for quiet.

Teacher tells class to do 5 more problems.

Ben turns around and

pokes Fran with pencil.

Teacher tells Ben, get to work,

NOW!

Ben calls out, this is too

hard. He throws
worksheet and book on
floor.

Teacher demands that Ben come

forward, get a hall pass, and go to
the office.

APPENDIX B

ABC OBSERVATION FORM

Student Name: Trish________________

Observation Date: 10/5__

Observer: Ms. Pasillas________________

Time: 9:40-9:55 a.m.____

Activity: disruptive behavior on the playground

Class Period: 3_________

ANTECEDENT

BEHAVIOR

CONSEQUENCE

Trish joins group of 4 girls playing catch.

Trish waits for ball to be
thrown to her.
Girls do not throw ball to Trish.
Trish yells Throw it to
me!
Girls throw ball to her, she
misses it and another girl,
LuAnne catches it and throws
it to Sandy.
Ball is again thrown to Karen.

Trish yells I said throw

it to me you jerk!

Karen begins to walk away with the ball.

Trish runs up behind

Karen and kicks her
saying Give it to me
damn it!

Karen cries. Trish takes

the ball.

FUNCTIONAL ASSESSMENT SCATTERPLOT

Student: _______________________________ Grade: ________ School:
______________________________
Date(s): _______________________________
Observer(s):_________________________________________
Behavior(s) of concern:
________________________________________________________________________

ACTIVITY

TIME
Monday

Tuesday

DAY OF
THE WEEK
Wednesday

TOTAL

APEX II Functional Behavioral Assessment

TOTAL
Thursday

Friday

FUNCTIONAL ASSESSMENT SCATTERPLOT

Grade: 6th

Student: Myree
Lynn
Date(s): 10/4/97 to 10/8/97

Observer(s):

School: John B.

Dennis

Behavior(s) of concern: disrupts class w/inappropriate comments and verbal threats directed at peers.

Setting:
__________________________________________________________________________________

ACTIVITY

TIME

MATH

9:2010:10
10:1011:00
11:0011:50

SCIENCE
SOCIAL
STUDIES

TOTAL

DAY OF
THE WEEK

Wednesday

TOTAL

Monday

Tuesday

Thursday

Friday

II

IIII

III

II

IIII

15

II

II

II

IIII

IIII

IIII

15

10

10

APEX II Functional Behavioral Assessment

PROBLEM BEHAVIOR QUESTIONNAIRE

Student ____________________________ Teacher _______________________

Date ________________

Student Behavior: Keeping in mind the problem behaviors identified in the Teacher Interview. Circle the frequency
at which each of the following statements is true.
Never

10% of
time

25% of
time

50% of
time

75% of
time

90% of
time

Always

1. Does the problem behavior occur and persist

when you make a request to perform a task?

2. When the problem behavior occurs, do you

redirect the student to get back to task or
follow the rules?

3. During a conflict with peers, if the student

engages in the problem behavior, do peers
leave the student alone?

4. When the problem behavior occurs, do peers

verbally respond or laugh at the student?

5. Is the problem behavior more likely to occur

following a conflict outside the classroom?
(e.g. bus write-up)

6. Does the problem behavior occur to get your

attention when you are working with another
student?

7. Does the problem behavior occur in the

presence of specific peers?

8. Is the problem behavior more likely to continue

to occur throughout the day following an earlier
episode?

9. Does the problem behavior occur during specific

academic activities?

10. Does the problem behavior stop when peers

stop interacting with the student?

11. Does the behavior occur when peers are

attending to other students?

12. If the student engages in the problem behavior,

do you provided one-to-one instruction to get
the student back on task?

13. Will the student stop doing the problem

behavior if you stop making requests or end an
academic activity?

14. If the student engages in the problem behavior,

do peers stop interacting with the student?

15. Is the problem behavior more likely to occur

following unscheduled events or disruption in
classroom routines?

APEX II Functional Behavioral Assessment

Student _____________________

Problem Behavior Questionnaire Profile

Peers
Escape
Question:
3
10
6
6
5
5
4
4
3
3
2
2
1
1
0
0

Peers
Attention
14
6
5
4
3
2
1
0

4
6
5
4
3
2
1
0

7
6
5
4
3
2
1
0

Adults
Escape
11
6
5
4
3
2
1
0

1
6
5
4
3
2
1
0

9
6
5
4
3
2
1
0

Adults
Setting Events
Attention______________________
13
6
5
4
3
2
1
0

2
6
5
4
3
2
1
0

6
6
5
4
3
2
1
0

12
6
5
4
3
2
1
0

5
6
5
4
3
2
1
0

8
6
5
4
3
2
1
0

15
6
5
4
3
2
1
0

Developed by Lewis, Timothy J., Scott, Terrance M., Sugai, George. (1994) Diagnostic,
19 (2-3), 1-3-115.

APEX II Functional Behavioral Assessment

FINAL REPORT
STUDENT ASSISTANCE TEAM
XY HIGHSCHOOL
FUNCTIONAL ASSESSMENT OF BEHAVIOR
DATE:
NAME:
BIRTH DATE
AGE:
PRIMARY LANGUAGE:

SCHOOL:
GRADE:
TEACHER:
EVALUATOR

REASON FOR REFERRAL

Name was referred to the evaluator by REFERRAL SOURCE. It is our hope that this
evaluation will aid in determining the function of the following behavior problem: PROBLEM
BEHAVIOR AS DEFINED BY REFERRAL SOURCE. From this assessment, a behavior
intervention plan will be developed.
These behaviors have interfered with Name's achievement of his/her academic goals and have
resulted in suspension/ failure from school. From this assessment a behavior intervention
program will be developed by the SAT.
At the time of referral Name displayed the following behaviors:
(list behaviors as identified by the referral source)

ASSESSMENT PROCEDURES
BACKGROUND INFORMATION
Data Collection Methods Used:
Indirect

Direct
___ Record Review
___ Behavior Logs/ Discipline Reports
___ Structured Interviews w/__________________
___ Reports from ___________________________
___ Rating Scales ___________________________

___ Consultant Observation

___ ABC Data Collection
___ Staff Direct Observation
___ Other Direct Data Collection_____________
___________________________________

Name is an age-year-old, grade-grade-sex who attends School. She/He has attended School
since Month, Year. School attendance has been attendance pattern.

APEX II Functional Behavioral Assessment

Behavioral History
From interviews (with) and record review it was learned that this behavior problem has
previously been displayed. (Describe history of behavior problem).
Previous interventions attempted to help manage this behavior problem have included the
following: (Describe prior interventions). The following intervention components appear to
have some potential and should be considered when developing Name's behavior intervention
plan: (Describe previously attempted interventions that were helpful). Alternatively, the
following components appear do not appear to have been helpful and should be avoided:
(Describe previously attempted interventions that were not helpful and should be avoided).
From this behavioral history a tentative hypothesis of the function(s) of the problem behavior
was (were) developed. It would appear that this behavior is positively- and/or negatively
reinforcing. Specifically, because of (Behavior problem) Name appears to obtain (List what
the behavior gets for the student). and/or Specifically, because of (Behavior problem)
Name appears to escape or avoid (Report what the behavior allows the student
Hypothesized Function of the Target Behavior
Based on this, what FUNCTION might the behavior be serving? (What is the student GETTING or AVOIDING by engaging in
the behavior)
INTERNAL

ACCESS / GET
Something

AVOID/ESCAPE
Something

EXTERNAL

___ Cognitive ________________________

___ Emotional _______________________
___ Communication
___ Control
___ Revenge
___ Sensory
___Auditory ___Visual
___ OTHER ___________________________

___ Attention _________________________

___ Cognitive _________________________

___ Emotional ________________________
___ Physiological ______________________
___ Sensory
___Auditory ___Visual
___ OTHER ___________________________

___ Setting __________________________

___ Task _____________________________
___ Activity __________________________
___ Person(s) _________________________
___ Academic Subject __________________
___ OTHER
___________________________

___ Tangibles
___ Activities _________________________
___ Other ____________________________

Replacement Behaviors
From interviews (with) it was determined that (State incompatible behavior) was a positive
alternative behavior incompatible with the target behavior. Specifically, (Provide a clear
behavioral description of the replacement behavior). This behavior would appear to obtain
the same goal as the target behavior.

APEX II Functional Behavioral Assessment

PROBLEM IDENTIFICATION:
Describe the BEHAVIOR(s) of concern (observable and measurable):
_1.______________________________________________________________________________________________
_2.______________________________________________________________________________________________
_3.______________________________________________________________________________________________

Consequences of the Replacement Behavior

Currently, consequences of Name's (Replacement behavior) include (List the result or
consequence of the replacement behavior for the student).
Potential reinforcers for the replacement behavior may include (From hypothesized function of
behavior, list possible reinforcers that may increase the replacement behavior).
Consequences Maintaining the Behavior/FUNCTION:

What events typically FOLLOW the behavior? (See ABC Data)

_____________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Behavior Intensity (How severe is the behavior?)

This data helps to document the severity of the target behavior. At the time of this assessment,
the behavior was rated as being a Level ? (On a scale of 1 to 5, with 5 being the most severe) on
a disruptive behavior rating rubric. This level of behavioral severity is defined as follows:
Level 1, Behavior is confined only to the observed student.
Level 2, Behavior disrupts others in the students immediate area.
Level 3, Behavior disrupts everyone in the class.
Level 4, Behavior disrupts other classrooms or common areas of the school.
Level 5, Behavior causes or threatens to cause physical injury to Name or others.
Behavior Duration (How long does the behavior last?)
Duration data reflects the time that the behavior was expressed from beginning to end. For the
purposes of baseline data collection, the behavior was judged to begin when Name (State
beginning criteria) and to end when (State ending criteria). Data from each of the (state # of
days) baseline data days was as follows:
Date
Duration
During the data collection period Name displayed the behavior for a total (Total amount of
time). On average the behavior lasted (Average).

APEX II Functional Behavioral Assessment

ESTABLISHING OPERATIONS THAT MAY INFLUENCE BEHAVIOR (SETTING EVENTS)

Also referred to as setting events or ecological variables, these events typically occur the
morning of or evening before a given behavior is displayed. They make it more or less likely
that a behavior will be judged as reinforcing (e.g., a student who is hungry will, find behaviors
that obtain food more reinforcing). They also influence the likelihood that a behavior will occur
(e.g., a student who is tired is more likely to display task avoidance behaviors). These events
were identified by rating scales, observation, interview, and/or record review.
Antecedent / Setting Events (Contextual Variables):
What conditions tend to SET OFF the behavior (look for patterns in ABC Data)?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
For whom is the behavior a problem? _________________________
For whom is the behavior NOT a problem? ____________________
Where does the behavior occur MOST often? ________________________________
LEAST often? _______________________________
At what time of the day does the behavior occur MOST often?
______________________LEAST often? ___________________________
During what activities does the behavior occur MOST often?________________________ Least
often?___________________________
Are the expectations for this student REASONABLE (describe)?
_____________________________________________________________
Are the adults in the students environment CONSISTENT (i.e: similar expectations, directions,
discipline strategies. Please describe)
_______________________________________________________
Are the adults in the students environment RESPECTFUL of the students
values/needs?________________________________________
Additional ANTECEDENTS / SETTING EVENTS Checklist (check/describe most relevant
contextual variables)
Medical/Emoti
onal
___
Hunger/Thirst
___ Restroom

Environmental
Social/

___ Auditory
___ Visual

Interactional
___ Social
Expectations
___ Opportunity

Curricular/
Instructional
___ Task Difficulty
___ Task Length

APEX II Functional Behavioral Assessment

Personal

___ChoiceMaking
___Communica

___ Health

___ Transition

___ Medication
___ Diet

___
Predictability
___ Class Size

___ Sleep

___ Seating

___ Clothing

w/ peers
___ Teacher /
Staff
___ Proximity
___ Behavior of
Peers
___ Necessary
Social Skills
___ Change of
Staff

___ Rate of Presentation

___ Delivery of
Instruction
___ Level of Assistance
___ Meaningful

tion
___Emotional
___Routine
Dependent
___Personal
Likes/Dislikes
___Coping
Skills

___ Variation of Material

DESCRIBE:
______________________________________________________________________________
__________________________________________________________________
________________________________________________________________________

APEX II Functional Behavioral Assessment

Behavior Support Plan,

Summary Statement of the Problem
Behavior Pathway
Maintaining consequences

Alternative Behavior

Setting event

Problem Behavior

Maintaining
consequences

Function

D esired Behavior

SUMMARY
This assessment was designed to help determine the function of the following serious behavior
problem: (Target Behavior). From this assessment it has been determined that the following
events are establishing operations for this behavior: (List events). Immediate antecedents or
triggers of the behavior appear to include (List Antecedents). The immediate consequences of
Names behavior problem typically include (Consequences). Given this result of his/her
behavior it is suggested that the problem behavior is negatively and/or positively reinforcing.
In other words, when Name engages in (Target Behavior) he/she is likely to obtain (Positive
Reinforcers) and/or escape and/or avoid (Negative Reinforcers).

APEX II Functional Behavioral Assessment

RECOMMENDATIONS
(Try to avoid combining recommendations. Be specific in each recommendation. Use scripting for teachers when
necessary. They should allow individuals not familiar with the student, the classroom, or even your assessment data
to implement what you recommend)

From this functional assessment of behavior the following behavior intervention program
recommendations are offered:
(Positive alternative behaviors)
List strategies that make the problem behaviors irrelevant, ineffective, & inefficient
Predictor (setting event)
Strategies (how to modify the
setting events)

e.g: Does not understand

work.

Behavior Modifications
(replace problem behaviors)

e.g: Blows up at teacher

Instructional Strategies
e.g:
1. Pre teach work at
beginning of class if
there is available
time.
2. Teacher report to
Mentor or Guidance
Counselor regularly
on homework
completion.
1. Say to Johnny, your
behavior right now is
inappropriate. Then
give him the option to
either take walk to the
drink fountain and
return within 2
minutes (If you are
not back by then, you
will be reported to the
office) or to calm
down and return to his
seat.
2. If refuses to
cooperate, follow
standard classroom
discipline procedure
for expressed
behavior.

APEX II Functional Behavioral Assessment

Consequence Strategies
1.Take a moment
after/before class to
thank Johnny for
doing work.
2. Be sure to thank
Johnny if he asks for
help with work.

1. If Johnny speaks
with the teacher after
class, thank him for
taking the time to
calm down and
speak about the
matter.
2. If Johnny goes a
week resolving
disputes with
teachers in a
reasonable manner,
then notify
Mentor/Guidance to
reward him with
drink/snack.

Connect

QUALITY OF LIFE INTERVENTIONS

The following interventions are geared towards improving the students life outside school in his
natural settings at home and social events. These types of interventions will ensure that NAME
will have a consistent reinforcement pattern across the board.
Personal Modifications: (modifications the student can do at home and /or social settings in
order to achieve the desired goals/ desired behaviors)
Check & Connect Monitoring Sheet
Month_______________ Student_____________________
ID_____________________
School_____________________________________
Monitor________________________
Chec
k

M T

W T
h

M T W T
h

M T

W T
h

M T

W T
h

M T

W T
h

Tardy
Skip
Absent
Behavi
or
Referr
al
Detent
ion
In
school
suspen
sion
Out of
school
suspen
sion

Failing
Classe
s/
behin
d in
Credit
s

_____ Ds
Total

____Fs _____Classes Passed out of ______ Total.

_____Credits earned out of _____

Basic
Shared general info

APEX II Functional Behavioral Assessment

Hig
h
Risk
For
Mon
th

Provided regular feedback

Discussed staying in school
Problem solved about risk

Intensive
Arranged for alternative to
suspension
Contracted for behavior or
grades
Communicated with parents
Made special
accommodations
Participated in Community
Service
Participated in school
sponsored activity
Participated in social skills
group
Worked with tutor or
mentor
Other:

APEX II Functional Behavioral Assessment

Family modification: (modifications that parents can do at home in order to achieve the desired
goals/ desired behaviors)

__________________________________ _______________________________
Parent/Guardian
SAT member
_________________________________
Other staff member involved

_______________________________
General Education Teacher

_________________________________
Student

APEX II Functional Behavioral Assessment

Behavior Support Plan Review

Student ____________________________________ Grade ____________
School _____________________________________ Date _____________
SAT monitoring member____________________________________
1. Review each task on the BSP Implementation plan to identify whether all tasks are being
implemented successfully answer below under
REVIEW DATA
Data Collected
Scatter-plot, point card, etc.

Summary of the data

# of occurrences/ patterns/ points
earned out of possible points)

Evaluation Decision
Goal Attained/ Reinforcement Earned

Is Plan Being
Implemented?

Is Plan Making a
Difference?

MODIFICATIONS TO THE BSP IMPLEMENTATION PLAN

Tasks

Person Responsible

By
When

Was task
Completed
consistently?

Evaluation
Decision
Monitor, Modify, or
Discontinue

Date & Time of the Next BSP Review meeting ________________________________

__________________________________ _______________________________
Parent/Guardian
SAT member
_
_________________________________
_______________________________
Other staff member
General Education Teacher

APEX II Functional Behavioral Assessment