Functional Behavior Assessment

Student name: _____________________________________ School ____________________________ Student ID#: ______________

Evaluator name: ________________________________________ Evaluator name: ________________________________________
List educational disability/ies ____________________________________________________________________________________
Function
1. Acts to gain attention or get a reaction from peers and/or staff
7. Acts to feel in control
2. Acts to gain access to desired item, activity, or person
8. Acts of revenge or retaliation, contrition or settling a difference
3. Acts to avoid a task or activity; escape a situation or consequence 9. Acts to demonstrate skill or talent
4. Acts to regulate sensory input (e.g., increase or decrease)
10. Acts for gratification, selfreward or self-determined pleasure
5. Acts to communicate feelings, wants, and needs
11. Inaccurate perception or misinterpretation of events or actions
6. Acts to connect with others or gain acceptance into a group
of others
Setting
Antecedent
1. Classroom
1. Given direction/task/activity
11. Given assistance/correction 21. __________________________
2. Hallway
2. Denied access to activity/item 12. Bothered by peers / bullying 22. __________________________
3. Cafeteria
3. Required to listen to instruction 13. Presence of a specific person
Severity
4. Bus
4. Difficult task/activity
14. Needs to wait
1. Behavior is not disruptive
5. Playground
5. Preferred activity disrupted
15. Attention given to others
2. Behavior is disruptive
6. Related service / office
6. Boring task/activity
16. Made a mistake
3. Behavior creates dangerous and
7. Before or after school
7. Required to sit quietly
17. Lost game
hostile environment
8. Medication administration 8. Schedule / routine changed
18. No task/activity
Duration
9. Other ________________ 9. Increased sensory input
19. Medication administration 1. < 1 min 3. 5-10 min
5. 1/2 1 hr
10. Other ________________ 10. Decreased sensory input
20. No antecedent
2. 1-5 min 4. 10-30 min 6. 1 hr+
Behavior

What has been tried?

Function

Antecedent

Settings

Duration

Severity

1.
2.
3.
4.
5.
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Antecedent

Setting

Duration

Function

Severity

How did staff react?

How did other students react?

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Does the student understand the behavior expectations? ______________________________________________________________
Does the student realize that he or she is engaging in unacceptable behavior? _______________________________________________
Does the student have the skills necessary to perform expected, new behaviors? ____________________________________________
Does the student have the skill but does not desire to modify his or her behavior? ____________________________________________