Charles County Public Schools

Charles County Public Schools

Functional Behavior Assessment

I. Student Information

Name of Student: Click here to enter text. / Date of Birth: Click here to enter text.
School: Click here to enter text. / Grade: Click here to enter text.
Current IEP? ☐ Yes ☐ No / IEP Disability: Click here to enter text.
Current 504? ☐ Yes ☐ No / 504 Disability: Click here to enter text.
Case Manager: Click here to enter text. / Current SST Plan? ☐ Yes ☐ No
Date of IEP/504/SST meeting to Obtain Permission for FBA/BIP: Click here to enter a date.
Date FBA and BIP Completed: Click here to enter a date.
Date of IEP/504/SST Team Review: Click here to enter a date.
Date(s) of Revisions: Click here to enter a date.
Click here to enter a date.
Click here to enter a date.

II. Reason for Referral (check all that apply)

The referral was initiated because the student:

☐Demonstrates a pattern of problem behavior that interferes with his/her learning

☐Demonstrates a pattern of problem behavior that interferes with others’ learning

☐Has repeatedly been removed from school activities due to problem behavior

☐Has repeatedly been removed from class due to problem behavior

☐Other. Please specify or list specific behaviors of concern: Click here to enter text.

III. Background Information

The team has reviewed the following background information:

☐Instructional levels/strategies:

Reading level Click here to enter text.

Math level Click here to enter text.

Brief summary of information: Click here to enter text.

☐Student’s strengths (academic and non-academic): Click here to enter text.

Brief summary of information: Click here to enter text.

☐Parent information (from interviews and/or parent conferences)

Brief summary of parent information: Click here to enter text.

☐Behavior checklists and/or rating scales

Name of instrument / Completed by / Dates completed
Click here to enter text. / Click here to enter text. / Click here to enter text.
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☐Observations

Name of observer / Setting / Date observed
Click here to enter text. / Click here to enter text. / Click here to enter a date.
Click here to enter text. / Click here to enter text. / Click here to enter a date.
Click here to enter text. / Click here to enter text. / Click here to enter a date.
Click here to enter text. / Click here to enter text. / Click here to enter a date.

IV. Specific Assessment Techniques Used to Analyze Behavior

☐ Observation / ☐ Teacher Input
☐ Parent Input / ☐ Behavior Checklist/Rating Scale
☐ Student Interview / ☐ Classroom Behavior Data
☐ Functional Analysis / ☐ Other. Please Specify.Click here to enter text.

Summarize all assessment techniques used: Click here to enter text.

V. Operational Definitions of Behaviors to Decrease (define in observable and measurable terms)

Behavior #1: Click here to enter text.

Behavior #2: Click here to enter text.

Behavior #3: Click here to enter text.

Antecedents / Problem Behavior / Consequences
Click here to enter text. / Click here to enter text. / Click here to enter text.
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VI. Replacement Behaviors

Skills to teach student in order to decrease problem behavior

Problem Behavior / Replacement Behavior
Click here to enter text. / Click here to enter text.
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VII. Using information from Section V, summarize factors/antecedents/settings that contribute to occurrence, non-occurrence, and/or maintenance of problem behaviors over time. Describe classroom structure including instructional changes. Develop a hypothesis regarding setting conditions and maintenance factors for each behavior (conditions under which behaviors are most/least likely to occur). Describe any situations or settings where problem behaviors don’t occur.

Click here to enter text.

VIII. Describe factors at home, in the community, or at school which may influence behavior during data collection (e.g. changes in environment; changes in medications; etc.)

Click here to enter text.

IX. Hypothesis Statement for the Function of the Behavior

State the hypothesized function for each behavior. Functions are:

☐ Attention

☐ Escape

☐ Access to Tangible Objects or Activities

☐ Sensory

Behavior #1: The function of Click here to enter text. is hypothesized to be

Click here to enter text..

Behavior #2: The function of Click here to enter text. is hypothesized to be

Click here to enter text..

Behavior #3: The function of Click here to enter text. is hypothesized to be

Click here to enter text..

X. Developers of FBA (Name and Title):

Name / Title
Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text.
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