Functional Behavioral Assessment MCPS Form 336-64

Office of Student and Family Support and Engagement August 2016

MONTGOMERY COUNTY PUBLIC SCHOOLS Page 1 of 4
Rockville, Maryland 20850

PART I

STUDENT INFORMATION:

Name _____________________________________________________ MCPS ID Number____________________ Date _____/_____/______

Date of Birth _____/_____/______ Grade _____ School _________________________________________________________________

General Education □ Section 504 □ Special Education □ (disability): ______________________________________________

TEAM INFORMATION: This form should be completed by a team that, at a minimum, includes one of the student’s classroom
teachers, the school counselor, and school psychologist/social worker.

Teachers: School Counselor:

Psychologist:
Social Worker:
Other Team Members:

BACKGROUND INFORMATION: (include information about change of schools, retention, Section 504, special education services
and/or supports, etc.)

Behavioral Data (include office disciplinary referrals, suspensions, critical incidents, etc.)

Student Strengths
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Current Academic Performance Levels

A. Reading:

B. Mathematics:

C. Written Expression:

Attendance/Health/Environmental Factors

Informal Teacher Observations

Description of Current and Past Behavior Interventions (e.g., behavior contracts).

(Attach MCPS Form 272-10: Documentation of Interventions)

A.

B.

C.

INITIAL DATA COLLECTED THROUGH THE FOLLOWING: (check all that apply—data for asterisked items is required and should be attached)
□ Record Review □ Parent Interview
□ Teacher Interview □ Student Interview
□ *Antecedent Behavior Consequence (ABC) chart □ *Structured observations
□ Anecdotal record □ Scatter plot
□ *Behavior management system □ Other
Is there enough data to continue a Functional Behavioral Assessment (FBA)?
□ Yes: Proceed with FBA □ No: Collect additional data and reconvene to complete FBA
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PART II

SPECIFIC DESCRIPTION OF PROBLEM BEHAVIOR(S): Use measureable, observable, and specific terms. Complete a separate
Part II for each behavior, unless they are closely related and serve the same function.

Problem Behavior(s) Intensity, Duration, Frequency

SETTING EVENTS: Identify situations or variables that make it more likely that the trigger will cause the problem behavior to occur
(e.g., weak academic skills, time of day, hunger, lack of sleep, changes in custody, etc.)

ANTECEDENTS: What happens just before the problem behavior? When is the behavior most likely to occur? (check all that apply)
□ Unstructured time □ Independent work
□ Large group instruction □ When student is not receiving attention
□ Small group instruction □ When given a directive
□ Transition □ When presented with a specific task
□ When told “no” or denied access to a preferred activity □ When unable to…
□ When with specific adult(s) □ When with specific peer(s)
□ Other
CONSEQUENCES (positive or negative): What occurs after the behavior?
□ Teacher attention □ Suspension
□ Peer attention □ Ignore
□ Verbal warning □ Removal from class to…
□ Loss of privilege □ Other
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POSSIBLE FUNCTION OF BEHAVIOR (the WHY of behavior):

1. Escape/Avoid:__________________________________________________ (specify—e.g., peer or adult attention, preferred activity,

sensory stimulation)

2. Access/Gain:___________________________________________________ (specify—e.g., peer or adult attention, preferred activity,

sensory stimulation)

SUMMARY STATEMENT:

When… ______________________________________________________________________________________________________________
(describe circumstances/antecedents)

the student… _________________________________________________________________________________________________________

(describe target behavior)

to get/to avoid… ______________________________________________________________________________________________________

(describe circumstances)

Is the Behavior a Skill Deficit or Performance Deficit? Can the student perform the desired behavior? If not, specify what needs
to be taught. If the student can perform the desired behavior, and does not, then it is a performance deficit.

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Replacement Behavior/Skills to be Learned: A replacement behavior is a more appropriate behavior that serves the same or
similar function as the problem behavior. Replacement behaviors also must be measureable, specific, and observable. The functionally
equivalent replacement behavior will be taught and reinforced to allow the student’s need (i.e., function) to be met in an acceptable
manner. However, the functionally equivalent replacement might not be the ultimate goal behavior. Describe skills to be learned to
perform the replacement and the ultimate goal behavior.

Example: It has been determined that a student acts disruptively in order to avoid difficult work. The student might be taught to use a
“break card” in order to ask for a break. This replacement will provide a short period of avoidance in a way that is acceptable
to the teacher. Meanwhile, the student should be taught other coping strategies for dealing with frustration. Teachers should
insure that work is appropriate for the student’s skills and implement academic interventions as needed.

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