Functional Behavioral Assessment (Fba)

FBA-Page 2 of 2 for Preschool and School Age

Name: ______

ID #: ______

New Hanover County Schools

Functional Behavioral Assessment (FBA)

Name______Review Student’s Strengths: Review Target Behavior: (See PBIS 4)

ID# ______

Date of Birth______

Meeting Date______

A Antecedents
Check factors noted prior to target behavior. /

B Behavior

Summarize behavior at each level of intensity from the data gathered during the last 2 weeks on the Frequency Data Sheet. Be specific, and look for patterns. / C Consequences
Check events that typically follow the target behavior.
r  Physical / medical (discomfort / change in meds?)
______
r  Social / emotional (with whom / negative
interaction / social skill deficit?)
______
r  Communication (understand instructions /
make needs known?)
______
r  Environmental / classroom (over-stimulated / noisy / crowded?)
______
r  Academic / instructional (too easy / too difficult / not interested / unorganized / large group / independent work?)
______
______
r  Setting events (response to command / transition / unstructured / change in routine/ bus / time / person / subject?)
______
______
r  Home (change in home / family dynamics?)
______
r  Other ______
______
______
______
______/ Mild:
Moderate:
Severe: / r  Internal / intrinsic pleasure
______
r  Teacher / adult attention
______
r  Peer attention
______
r  Verbal warning / reprimand
______
r  Loss of privilege (what kind? school? home?)
______
r  Time out (where? how long?)
______
r  Detention (how long? what kind?) (include #)
______
r  Removal from class (bounced) (include #)
______
r  Office referral (include #)
______
r  Restitution (what kind?)
______
r  In school suspension (how long?)
______
r  Out of school suspension (how long?)
______
r  Legal charges (what kind?)
______
r  Bus referrals/suspensions (include #)
______
r  Other ______
Function of Target Behavior
What does the student gain from this behavior? / Hypothesis
What variables appear to trigger this behavior?
What does the behavior look like?
What seems to reinforce this behavior?
q  Attention from:
q  Peers ______
q  Staff ______
q  Preferred adult ______
q  Power:
q  Control ______
q  Intimidation ______
q  Vengeance ______
q  Escape / avoidance of:
q  Activity or task ______
q  Particular person ______
q  Classroom ______
q  Self-stimulation to reduce :
q  Anxiety ______
q  Fear ______/ Example:
When Johnnie is in small group instruction and/or gym (SETTING) and does not get his way (ANTECEDENT / CONTEXT), he typically responds by shoving and/or using threatening language (BEHAVIOR) to gain attention (FUNCTION).
Fill in the blanks to complete your hypothesis:
When student is ______
(SETTING)
and ______
(ANTECEDENT / CONTEXT)
he/she typically responds by
______
(BEHAVIOR)
to gain ______
(FUNCTION)
If this is a specific/one time incident that is being considered for long-term suspension, then describe the incident.

For a list of meeting participants, see SST/IAP Attendance Log or IEP Page 1.