FBA Date: __________________________________

BIP Initiation and Review Date: _________________

FUNCTIONAL BEHAVIOR ASSESSMENT (FBA)

Student: School:
Staff Involved:
Grade:

A. Student Strengths/Interests/Motivators:

B. Reason for conducting Functional Behavior Assessment:

C. Background Information:
The team has reviewed the following information. Fill out/Attach all that apply.
Parent Information:

Behavior Checklists and Rating Scales:

Observations (Collect measurable data during your observation; consider if the behavior is best measured by frequency, duration, response latency,
or intensity.)

Discipline Records, School Records, Attendance History

Health Information
Information from Outside Agencies (if applicable) n/a
Other Information

D. Behaviors:
Describe in detail behavior(s) the student exhibits in the school setting that impedes learning, beginning with the most severe. If applicable, prioritize the
top one or two measurable/quantifiable behaviors. (e.g. DO NOT use “Bob was disruptive” DO USE, “Bob verbally shouted at peer/teacher after being
given a directive.”)

Priority Behavior(s):
1. Self-Control-Physical and Verbal 2. Compliance

Skill(s) the student is lacking that may be impacting his/her behavior (check all that apply):
____Communication skills (e.g. expressive, receptive, language barrier)
____Social Skills (e.g. skill deficit vs. motivation or context with which to display)
____Self-Control (e.g impulsivity, response to stimuli)
____Emotional Regulation (e.g. display emotions appropriately in regards to situation)
____Academic (e.g. frustration or inability to succeed academically)
____Other (please specify:____________________________________________________________________)
Prior Interventions and/or Response to Interventions: (If it’s not documented, it didn’t happen!) Please be specific and use
measurable terms.

FBA CONTINUUM
Behavior #1 Behavior #

Antecedent (Consider time, place, subject,

people, activity, environment)

Behavior (objective, specific in description) Behavior: Behavior:

Indicate at least one method of Frequency: Frequency:

FBA Date: __________________________________
BIP Initiation and Review Date: _________________
measurement: .
*This data often becomes your baseline for
interventions Duration: Duration:

Intensity (define and quantify intensity levels):

Amount of force behind the behavior (e.g. Peter banged his Intensity (define and quantify
head on his desk with an intensity level of 2) force behind the behavior (e.g
his desk with an intensity leve

Consequence (What typically happens - -

following the behavior?) This can be positive or
negative

What Consequences are maintaining

the behavior?
What consequences may be reinforcing to the
problem behavior?
AND
List the environments/times the student is
Successful Environments: Successful Environments:
successful. - -

Function of Behavior ____Escape/Avoidance _____Sensory Needs ____Escape/Avoidance

____Attention _____Other (Specify): ____Attention
____Tangible ___________________ ____Tangible

BEHAVIOR INTERVENTION PLAN (BIP)

Behavior Expectations for all students, in relation to behaviors of concern(s). (What should they be doing?)
“Most students are able to…”
New/Replacement How it will be taught? Who will teach the skill? When/Where?
behavior(s)/skill(s) (Consider social skills programs,
What new skills need to be taught in emotional regulation programs,
order to learn a functionally specific interventions)
equivalent replacement behavior?

1. Most students are able to

control their bodies and voices
to match the activity in the
classroom, without disruption
or distraction.

2. Most students are able to -Use of student timer?

complete an assigned task
without hesitation, distraction,
or argument.

3.

Daily Structure and Supports to meet student need(s)

Physical Setting:
(Noise, lighting, temperature, crowding)
___ Dim classroom lighting
___ Noise cancellation headphones
___ Time-away or Cool-down location
___ Visual boundaries
The degree of participation: Social Interaction:
(group size, location, and participant (social communication matching instructional opportunities)
parameters) ___ Peer mentor
____ provide participation prompt ___ Talk Time
___ Participates in a small group ___ Adult mentor
instead of the whole group ___ Other (specify)
___ Independent work in a quiet
FBA Date: __________________________________
BIP Initiation and Review Date: _________________
___ Other (specify) setting
___ Other (specify)

Social setting: Activities: Scheduling factors:

(interactions, patterns around the student)
___ Preferential Seating to peer/staff
___ 3:1 Positive Interaction Ratio
___ Other (specify)
(activities/curriculum to match learner needs)
___ Meaningful/Purposeful work
___ Modified Assignments)/Tests
___ Chunk Assignments
___ Sensory Breaks
___ Other (specify)
(timing, sequencing, and transition issues)
___ Late Start/early release
___ Visual schedule
____ Late/Early Transition
___ Adult Support during a transition(s)
___ Other (specify)

List transitional behaviors (behaviors that indicate a student is anxious or under stress). These occur before the state of
crisis (pacing, clenching fists, laying head on desk, deep breathing, tapping a pencil, crawling under the desk):
1.
2.
3.

De-escalation Strategies (e.g. offer a cool down space, provide purposeful movement, sensory breaks, break cards,
taking a walk) :
1.
2.
3.

Staff and environmental supports during the crisis (e.g. staff located by exits, no staff talking, staff watching clock, step
back and provide space, staff to student ratio):
1.
2.
3.

Corrective procedures for challenging behaviors (e.g. parent contact, contact support staff, phone Mental Health Center):
1.
2.
3.

Baseline:_________________________________________________________________________________________
________________
INTERVENTION
GOAL:___________________________________________________________________________________________
___
Please reference behavior data noted within the FBA continuum for baseline. Your goal and baseline measurement
method should be the same.
Example:
Baseline: In a 20-minute data collection period, Bob talked out 42 times (frequency = measurement method).
Goal: In a 20 minute data collection period, Bob will talk out no more than 10 times (frequency = measurement method)
FBA Date: __________________________________
BIP Initiation and Review Date: _________________
Example:
Participants signatures:
Name Role/Responsibilities Date
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________________________