Pasco County Schools

Pasco County Schools

PASCO COUNTY SCHOOLS

Approved Interviews

Student Functional Assessment Interview and Reinforcement Survey

Functional Analysis Interview Form (FAIF) – Teacher

Functional Behavior Assessment Teacher Report

Functional Behavior Assessment Parent Report

Functional Behavior Assessment Student Report

Functional Assessment Interview (FAI) – Family Version

Functional Assessment Interview (FAI) – Student Version

Functional Assessment Interview (FAI) – Teacher Version

Pasco County Parent Input Form – Short

Pasco County Parent Input Form – Standard

Pasco County Parent Input Form – Long

PASCO COUNTY SCHOOLS

CONFIDENTIAL AND PRIVILEGED STUDENT INFORMATION FOR PROFESSIONAL USE ONLY
Student Functional Assessment Interview and Reinforcement Survey
Demographics
Student: / ID#: / Date:
School: / Grade: / DOB:
Exceptionality: / Medical Dx: / Medications:
Teacher: / Case Manager: / Informant:
Team:
Section 1
In general, is your work too hard for you? / Always / Sometimes / Never
In general, is your work too easy for you? / Always / Sometimes / Never
When you ask for help appropriately, do you get it? / Always / Sometimes / Never
Do you think work periods for each subject are too long? / Always / Sometimes / Never
Do you think work periods for each subject are too short? / Always / Sometimes / Never
When you do seatwork, do you do better when someone works with you? / Always / Sometimes / Never
Do you think people notice when you do a good job? / Always / Sometimes / Never
Do your think you get the points or reward you deserve when you do good work? / Always / Sometimes / Never
Do you think you would do better in school if you received more rewards? / Always / Sometimes / Never
In general, do you find your work interesting? / Always / Sometimes / Never
Are there things in the classroom that distract you? / Always / Sometimes / Never
Is your work challenging enough for you? / Always / Sometimes / Never
Section 2
Answer for each target behavior

Target Behavior #1: ______

Target Behavior #2: ______

When do you think you have the fewest problems with this behavior?

When do you think you have the most problems with this behavior?

Why do you have problems during these times?

What changes could be made so that you have fewer problems with this behavior?

Section 3
Rate how much you like the following subjects
Reading / Not at all / Fair / Very Much
Math / Not at all / Fair / Very Much
Spelling / Not at all / Fair / Very Much
Handwriting / Not at all / Fair / Very Much
Science / Not at all / Fair / Very Much
Social Studies / Not at all / Fair / Very Much
English/Language / Not at all / Fair / Very Much
Music / Not at all / Fair / Very Much
Physical Education / Not at all / Fair / Very Much
Art / Not at all / Fair / Very Much
Other / Not at all / Fair / Very Much
Section 4
Reinforcement Survey

Part 1 Sentence Completion

Directions: Complete the following statements

  1. My favorite adult at school is:

The things I like to do with this adult are:

  1. My best friend at school is:

Some things I like to do with my best friend at school are:

  1. Some other friends I have at school are:

Some things I like to do with them are:

  1. When I do well in school, a person I'd like to know about it is:
  1. When I do well in school, I wish my teacher would:
  1. At school, I'd like to spend more time with:

Some things I'd like to do with this person are:

  1. One thing I'd really like to do more in school is:
  1. When I have free time at school I like to:
  1. I feel great in school when:
  1. The person who likes me best at school is:

I think this person likes me because:

  1. I will do almost anything to keep from:
  1. The kind of punishment at school that I hate most is:
  1. I sure get mad at school when I can't:
  1. The think that upsets my teacher the most is:
  1. The thing that upsets me the most is:

Part II Reinforcers
Some things I like are (check all that apply)

Favorite Edible Reinforcers Favorite Tangible Items

_____ Candy (specify) _____ Stuffed animals

_____ Fruit (specify) _____ Pencils, pens, crayons

_____ Drinks (specify) _____ Paper (specify)

_____ Cereal (specify)_____ Trucks, tractors

_____ Snacks (specify) _____ Sports equipment (specify)

_____ Nuts (specify) _____ Toys (specify)

_____ Vegetables (specify) _____ Books (specify)

_____ Other (specify) _____ Puzzles

Academic Reinforcers Social Reinforcers

_____ Going to library _____ Teaching things to other people

_____ Having good work displayed _____ Being the teacher’s helper

_____ Getting good grades _____ Spending time with my friends

_____ Having parents praise good schoolwork _____ Spending time with the teacher

_____ Giving reports _____ Spending time with the principal

_____ Making projects _____ Spending time with

_____ Completing creative writing projects _____ Having class parties

_____ Earning teacher praise _____ Working with my friends in class

_____ Helping grade papers _____ Being a tutor

_____ Getting a good note home _____ Being a leader in the class

_____ Earning stickers, points, etc. _____ Other (specify)

_____ Other (specify) _____ Other (specify)

Activity Reinforcers Recreation/Leisure Reinforcers

_____ Coloring/drawing/painting _____ Listening to music

_____ Making things (specify) _____ Singing

_____ Going on field trips _____ Playing a musical instrument

_____ Taking care of/playing with animals _____ Watching TV

_____ Going shopping _____ Cooking

_____ Eating out in a restaurant _____ Building models

_____ Going to movies _____ Woodworking/carpentry

_____ Spending time alone _____ Favorite sports (specify)

_____ Reading _____ Working with crafts

_____ Having free time in class _____ Other (specify)

_____ Having extra gym/recess time _____ Other (specify)

_____ Working on the computer _____ Other (specify)

_____ Other (specify) _____ Other (specify)

PASCO COUNTY SCHOOLS

CONFIDENTIAL AND PRIVILEGED STUDENT INFORMATION FOR PROFESSIONAL USE ONLY
Functional Analysis Interview Form (FAIF) – Teacher Version
Demographics
Student: / ID#: / Date:
School: / Grade: / DOB:
Exceptionality: / Medical Dx: / Medications:
Teacher: / Case Manager: / Informant:
Team:

The following interview should be conducted with the student’s teacher (s), or other school staff. The interview was adapted from the Functional Analysis Interview Form (O’Neill, Horner, Albin, Storey, & Sprague, 1990). The interview is designed to gather data from school staff about the target behavior. School social workers are skilled interviewers. This instrument should be used as a guide only. Questions that are not relevant to a particular student should be skipped. Additional questions may be added.

  1. What is the behavior of concern? How does this behavior impact the student’s school performance? Rank order

problem behaviors beginning with those that are the most problematic. (Make sure that the behavior is defined in a way

that can be observed and measured.)

  1. ______
  2. ______
  3. ______
  4. ______
  1. When did this behavior (identified as # 1 on the list) begin?
  1. What do you think causes (or motivates) this behavior?
  1. When is the problem behavior most likely to occur?
  1. How often does the problem behavior occur?
  1. Are there any times during the school day when the problem behavior does not occur?
  1. Are there any times when the problem behavior always occurs?
  1. Does the problem behavior occur more often during certain times of the day?
  1. Does the problem behavior occur in response to the number of people in the immediate environment?
  1. Does the problem behavior occur only when the student is with certain people?
  1. Does the problem behavior occur only during certain subjects (or during certain activities)?
  1. Could the problem behavior be related to any skill deficits?
  1. What is reinforcing for this student?
  1. Is the student taking any medications that might affect his/her behavior?
  1. Could the student’s problem behavior be signaling some physical discomfort such as being hungry, thirsty or needing

more rest?

  1. Could the problem behavior be the result a physical problem like a headache, a stomachache, blurred vision, or an ear

Infection?

  1. Could the problem behavior be caused by allergies?
  1. Does the problem behavior occur along with other behaviors?
  1. Are there any observable events that signal that the problem behavior is about to occur?
  1. After the problem behavior occurs, what usually happens?
  1. Do you have any additional questions or concerns about this student or about the problem behavior?

______

O’Neill, R.E.; Horner, R.H.; Albin, R.W.; Storey, K. and Sprague, J.R.. (1990) Functional analysis of problem behavior: A practical assessment guide. Sycamore Publishing, Sycamore, Il.

PASCO COUNTY SCHOOLS

CONFIDENTIAL AND PRIVILEGED STUDENT INFORMATION FOR PROFESSIONAL USE ONLY
Functional Behavior Assessment Teacher Report
Demographics
Student: / ID#: / Date:
School: / Grade: / DOB:
Exceptionality: / Medical Dx: / Medications:
Teacher: / Case Manager: / Informant:
Team:

1.List Student’s Strengths/Skills/Interests:

______

  1. List Student’s Behavior(s) of Concern:

Behavior / Frequency / Duration / Intensity
Make sure that the behavior is defined in a way that can be observed & measured. / Use Ratings Below

Frequency Rating: 1 = hourly2 = daily3 = weekly4 = monthly

Duration Rating:1 = few seconds2 = few minutes3= 15-30 minutes4 = greater than 30 minutes

Intensity Rating 1 = extremely high2 = high3 = medium4 = low

3.For how long have these behaviors occurred? <1 month 1-2 months 3-6 months >6 months

4.Is student receiving special education/other support services? _____ No _____ Yes

If yes, please describe______

5.Is the student currently experiencing an attendance problem?_____ No _____ Yes

If yes, please describe: ______

6.Is student currently on a behavioral plan?_____ No_____ Yes *If yes, please attach a copy

  1. Can you anticipate the student’s behavior? _____ No_____ Yes

If yes, please describe: ______

8.What skill(s) is the student missing that may improve behavior?

______

9.What do you think causes or motivates the behavior(s)?

______

10.What activities/incentives seem to be motivating for the student?

______

  1. Complete the following:

Subject / Grade level comparison / Problem Bx present / % of work turned in
Well Below / Below / At / Above / Many / Few / None / <20 / 20 to 50 / 50 to 70 / 70 to 90 / >90
Reading
Math
Spelling
Writing
Science
Social Studies
Art
Music
Computers
Other:

Other Current Academic Concerns? ______

ReinforcementDescribe what reinforcers the student has been able to earn for appropriate behavior(s)? / Effectiveness0=low 4=high
ConsequencesWhat have been the consequences for the student’s behavior(s) of concern? / Effectiveness0=low 4=high

12.Describe the student’s escalation pattern. Indicate what the student does when you administer a consequence? What you do in return and what is the student’s response. How does this interaction end?

______

______

Please attach a copy of your current classroom BEHAVIOR MANAGEMENT PLAN and CLASSROOM RULES.

______

This form created by: Kelly Rogers, S.Psy.S.; Behavioral Consultant; Delta-Schoolcraft ISD

PASCO COUNTY SCHOOLS

CONFIDENTIAL AND PRIVILEGED STUDENT INFORMATION FOR PROFESSIONAL USE ONLY
Functional Behavior Assessment Parent Report
Demographics
Student: / ID#: / Date:
School: / Grade: / DOB:
Exceptionality: / Medical Dx: / Medications:
Teacher: / Case Manager: / Informant:
Team:

Child lives at home with:

___ Natural Mother ___ Step-Mother ___ Adoptive Mother___ Foster Mother

___ Natural Father ___ Stepfather ___ Adoptive Father___ Foster Father

___ Girlfriend/Boyfriend ___ Biological Siblings ___ Stepsiblings ___½ Siblings

List everyone living in the home:

Name / Relationship / Age / Learning/Behavior Concerns?
Continue on back, if needed.

1.List your child’s strengths / skills / interests:

______

______

2.List your child’s challenges/areas of difficulty:

______

______

3.Does your child have behavior problems at home? ___ yes ___ no If so, describe:

______

______

4.Do you consider your family to be under stress at this time? ___ yes ___ no If so, describe:

______

______

  1. What types of discipline do you use with your child?

______

______

Answer the following regarding the child’s history / Yes / No / Briefly Describe
Difficulty Sleeping?
Poor Eating Habits?
Health Problems?
Court Involvement?
Psychiatric Diagnosis?
Taking Medication?
History of Abuse/Neglect?
Substance Use/Abuse?
Counseling Services?
Other Agency Involvement?

6.Please provide any other information you feel would be helpful to us in working with your child at school?

______

______

______

______

______

______

7.What would you like to see changed at your child’s school that would help with his/her behavior?

______

______

______

______

______

______

______

This form created by: Kelly Rogers, S.Psy.S.; Behavioral Consultant; Delta-Schoolcraft ISD

PASCO COUNTY SCHOOLS

CONFIDENTIAL AND PRIVILEGED STUDENT INFORMATION FOR PROFESSIONAL USE ONLY
Functional Behavior Assessment Student Report
Demographics
Student: / ID#: / Date:
School: / Grade: / DOB:
Exceptionality: / Medical Dx: / Medications:
Teacher: / Case Manager: / Informant:
Team:
What are your favorite activities at school?
What are your least favorite activities at school?
What are your hobbies / interests?
Check the appropriate box for each question / YES / Not Sure / NO
In general, is academic work too hard for you?
In general, is academic work too easy for you?
When you ask for help appropriately, do you get it?
When you do seat work, do you do better when someone works with you?
Do you think people notice when you do a good job?
Do you think you would do better in school if you got more rewards?
In general, do you find schoolwork interesting?
Is your work challenging enough for you?
What are the things that get you into trouble or are a problem at school?
How often does the behavior occur? / > Once a day / Daily / Weekly / Monthly
How long does the behavior last when it occurs? / Few seconds / Few minutes / < 30 minutes / > 30 minutes
Answer the following in reference to your behavior listed above
Most Problems / WHY? / Least Problems / WHY?
With Whom?
Where?
When?
What do you think triggers the behavior?
What do you get out of the behavior?
What changes could be made so you would have fewer problems with these behaviors?
Is there anything you would like to earn for appropriate behavior / work completion? If so, what?

_

______

This form created by: Kelly Rogers, S.Psy.S.; Behavioral Consultant; Delta-Schoolcraft ISD

PASCO COUNTY SCHOOLS

CONFIDENTIAL AND PRIVILEGED STUDENT INFORMATION FOR PROFESSIONAL USE ONLY
Functional Assessment Interview (FAI) – Family Version
Demographics
Student: / ID#: / Date:
School: / Grade: / DOB:
Exceptionality: / Medical Dx: / Medications:
Teacher: / Case Manager: / Informant:
Team:

Directions: The following interview should be conducted with the student’s family.

The interview was adapted from the Functional Analysis Interview Form (O’Neill, Horner, Albin, Storey, & Sprague, 1990). The interview is designed to gather data from the family about the behavior identified as a problem at school, and about their concerns related to behavior outside of school. School social workers are skilled interviewers. This instrument should be used as a guide only. Questions that are not relevant to a particular student should be skipped. Additional questions may be added.

1.What is your understanding of the behaviors that are a problem for your child / grandchild at school?

2.Are these behaviors that are a problem at school happening at home or in other places?

3.Do you consider these behaviors that are a problem at school, to be a problem at home or in other settings?

4.Have you been concerned about these or other behaviors?

  • If there is more than one problem behavior, list the behaviors in the order of their significance to the family.
  • Make sure that the behavior is defined in a way that can be observed and measured.
  • Remember that the highest priority for the family may not be the same behavior identified by the school. It is important to help the family with the behavioral concern that is most significant to them. The information related to the problem behaviors at home may help the team understand the behaviors that are a problem at school even if they are different behaviors.

a.

b.

c.

d.

5.When did the problem behavior (#1 on the list above) begin?

6.How did you respond when the problem behavior first started?

7.What do you think causes or motivates the problem behavior?

8.When is the behavior most likely to occur?

9.How often does this behavior occur?

10.Are there times when this behavior rarely or never occurs?

11.Are there times when this behavior almost always occurs?

12.Does this behavior occur more often during certain times of the day?

13.Is this behavior affected by how many people are around your student?

14.Does this behavior only occur when your student is with certain people?

15.Does this behavior occur only during certain types of activities?

16.Could this behavior be related to something your student has difficulty doing or to skills he/she hasn’t learned?

17.What is something your student likes so much it could be a reward?

18.Is your student taking any medications that might affect his/her behavior?

19.Could the behavior be related to being thirsty, hungry or tired?

20.Could this behavior be the result of any form of discomfort such as headaches, stomachaches, blurred vision, ear infections, etc.?

21.Could this behavior be caused by allergies?

22.When the problem behavior occurs, are there any other behaviors that are likely to occur with it?

23.Are there any observable events (outside of school) that signal that the problem behavior is about to occur?

24.What usually happens after the problem behavior?

25.Is there anything else that we haven’t already talked about, that you would like the school to know about your child or your child’s behavior?

______

O’Neill, R.E.; Horner, R.H.; Albin, R.W.; Storey, K. and Sprague, J.R. (1990) Functional analysis of problem behavior: A practical assessment guide. Sycamore Publishing, Sycamore, IL

PASCO COUNTY SCHOOLS

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