BEHAVIOR ASSESSMENT FORM
Child’s Name:Behavior problems to be addressed:
Assessment completed by:Date of Assessment:
This assessment is designed to identify factors that may influence the occurrence of the targeted behavior. The information should also serve as a basis for identifying relevant factors that may influence change in the behavior once it has occurred.
RELATIONSHIP OF THE HISTORY:
●What is your relationship to the child?
Teacher____ PM____ CA____ SNA____ FA____NA____BP____
Parent/Guardian____
●How long have you known the person?Years____Months____
●What is your frequency of interactions with the person?Daily____ 2-3 times per week____ Once per week____ Other______
●In what situations do you interact with the person? (Please check all that apply)
Personal care ____ Individualized instruction____ Meal time ____ IE time____
Evening hours ____ Day time hours ____ Bus/transportation ____ Other ______
SOCIAL INFLUENCES:
- Does the behavior occur after someone has placed a demand on, or
made a request of the person?y____ n____
2. Does the behavior occur when you walk away from the person?y____ n____
3. Does the behavior occur when you ignore the person?y____ n____
4. Does the behavior occur when you give attention to another person
in their presence?y____ n____
5. Does the behavior occur when you take away or prevent them from
interacting with others?y____ n____
- Are any of the behaviors associated with above incidents
accompanied by an emotional response like crying, yelling out, etc.?y____ n____
*Original – Child’s File
*Send copy to Disabilities/Prevention/Mental Health Manager
ECDHS804A REV 7/10
SOCIAL REINFORCEMENT:
7. Does the behavior occur when the person is not receiving much attention?y____ n____
- When the behavior occurs do you respond by interacting with them in
manner, verbally, physically, etc.?y____ n____
9. Does the person display annoying behaviors that receive attention?y____ n____
10. Does the person engage others to gain attention?y____ n____
11. Does the behavior occur when giving them a lot of attention?y____ n____
12. Does the behavior occur when a favored item is removed?y____ n____
13. Does the behavior occur when a favored activity is over or stopped?y____ n____
14. Does the behavior occur when the person can not have a favored item
or participate in a favored activity?y____ n____
15. Is there an absence of the behavior when the person has access to the
favored item or favored activity?y____ n____
16. Does the behavior occur during times where demands are placed on them?y____ n____
17. Is the person noncompliant when asked to complete a task?y____ n____
18. Does the behavior occur in crowded noisy environments?y____ n____
19. When the behavior occurs is the person allowed to take a break from the task?y____ n____
20. Does the behavior occur when there are few demands placed on them?y____ n____
NON-SOCIAL OR AUTOMATIC REINFORCEMENT
21. Does the behavior occur when the person is alone or unoccupied?y____ n____
22. Does the behavior occur at a high rate no matter what is going on around them?y____ n____
23. Does the person have very few reinforcers?y____ n____
24. Does the person interact appropriately with peers or objects?y____ n____
25. Does the person engage in repetitive or stereotypic behaviors?y____ n____
26. Is the person generally unresponsive to social stimuli?y____ n____
27. When the behavior is displayed do you respond by doing nothing?y____ n____
28. Is there a cyclical pattern to the behavior?y____ n____
29. Does the behavior occur when the person is ill?y____ n____
30. Is there a history of recurring illnesses?y____ n____
SCORING SUMMARY:
(count the items answered yes the more answered yes indicate the behavior listed)
Score 1 thru 10, this indicated attention-seeking behavior.total:______
Score 1 thru 4 and 11 thru 15, this indicated a need to access behavior.total:______
Score 1 thru 4 and 16 thru 20 this indicates escape/avoidance behavior.total:______
Score 21 thru 26, this indicated need for sensory stimulation.total:______
Score 21 thru 26 and 26 thru 29, this indicates attention caused from paintotal:______
*Original - Child’s File
*Send copy to Disabilities/Prevention/Mental Health Manager
ECDHS804B REV 7/10