COMPREHENSIVE FUNCTIONAL ASSESSMENT

OF STUDENT BEHAVIOR

SUMMARY

Date of Summary:______

Student:______School:______

I. General Information:

A. Strengths, Weaknesses, Interests: ______

______

______

B. Parent involvement (significant home, family, living situation issues): ______

______

______

C. Medical/Health Factors (diagnoses, medication or other treatment, compliance with treatment):

______

______

______

D. Current Education Status (attendance, achievement, grades, progress toward graduation, academic deficits): ______

______

II. Write an operational definition (observable/measurable) of the behaviors that are of greatest concern using the above information. (e.g. During transition time in the hallway, Jane strikes peers with an open hand on the back for 2 seconds 3 times a day with no physical injury.)

______

______

______

III. Baseline Data

  1. Frequency

How often does the behavior occur?

_____times per______(e.g. three or four times per hour)/______[specific behavior(s)]

____times per______/______(specific behavior)

B. Duration

How long does the behavior last when it occurs? (e.g. disrupts class for 10 to 15 minutes at a time, arrives 3 to 10 minutes late to class; state duration for each target behavior where duration is applicable)

______

______

______

C. Intensity

How damaging or destructive is the behavior? (e.g. resulting in physical injury, resulting in class loss of instructional time)______

______

______

  1. When is the problem behavior most [M]/ least [L] likely to occur?

_____morning/ approximate time _____lunch

_____afternoon/ approximate time _____recess

_____before/ after school _____other______

Specifics, if known:______

  1. Where is the problem behavior most [M]/ least [L] likely to occur:

_____classroom/ (______specific subject) _____hallway

_____cafeteria _____bus

_____playground _____other______

F. During what type of activity is the problem behavior most [M]/ least [L] likely to occur?

_____independent seat work _____transition

_____small group instruction _____unstructured activities

_____lesson presentation _____task explanation

_____other______

G. People with whom the problem behavior is most [M]/ least [L] likely to occur?

_____teacher (all teachers?____/specific teacher?_____)

_____classmates

_____other staff

_____other______

IV. Identify from the checklists below factors that appear to “set off” and/or precede the problem behavior (antecedents):

  1. Teacher behaviors:

_____task explanation/demand

_____performance feedback

_____lesson presentation/lecture

_____teacher reprimand

_____teacher encouragement/praise

_____individual attention to student

_____independent work/lack of teacher interaction

_____other______

B. Student behaviors:

_____drowsy/sleep appearance

_____physical complaint (hunger, pain, etc.)

_____disturbed affect (sad, angry, etc.)

_____excessive motor activity (fidgety, restless)

_____negative peer attention

_____positive peer attention

_____other______

C. Environmental factors:

_____excessive noise level

_____presence of unusual/extra adult

_____presence of unusual/extra peer

_____transition task/activity (expected routine)

_____transition task/activity (unexpected/irregular)

_____access/availability of preferred activity/task

_____termination of preferred activity/task

_____access/availability of food

_____other______

V. Identify from the checklists below factors that appear to maintain and/or follow the occurrence of the behavior (consequence):

A. Teacher behaviors:

_____teacher reprimand

_____teacher encouragement/praise

_____task removal

_____withdrawal of teacher attention/ignoring

_____other______

B. Student behaviors:

_____negative peer attention

_____positive peer attention

_____withdrawal of peer attention/isolation

_____other______

C. Environmental factors:

_____access/availability of preferred activity/task

_____removal of student to alternative setting

_____other______

VI. Identify from the checklists below what the student gains/avoids by engaging in the problem behavior (possible functions/ “pay offs” of the problem behavior):

  1. The student gains:

_____teacher/adult attention _____control over others or the situation _____gratification

_____peer attention _____acceptance/approval _____revenge

_____desired item or activity _____self stimulation _____other______

  1. The students avoids:

_____attention _____non-preferred activity/task _____other______

_____teacher/adult interaction _____non-preferred setting

_____a difficult task _____peer interaction

VII. Hypotheses statement: using information from the above sections construct a hypothesis statement.

When______,

(summarize antecedents and setting events)

this student______,

(identify problem behavior)

in order to______.

(summarize possible functions/pay offs)

Examples: 1. When in the halls before school and during transitions, this student pushes other

students and verbally threatens to beat them up in order to gain status and attention

from peers.

  1. When working on independent seatwork during his regular education math class,

this student puts his head on his desk in order to escape work that is too difficult/frustrating.

Participants/Signatures (list name and position):

______

______

______

Sources of information (check all which are applicable):

_____Cumulative record

_____Disciplinary record

_____Parent interview

_____Student interview/preference survey

_____Observation conducted by behavioral specialist

_____Baseline data