Functional Behavior Assessment Interview/Information

The Functional Behavior Assessment (FBA) examines the content, pattern, and function of the students behavior
and leads to an effective Behavior Intervention and Support Plan (BISP).
*This form may be completed (using computer or ink) by a school team familiar with the student.

Name: Student ID: Date:

DOB: Age: Grade: Building/Site:

Form completed by: Date of last IEP:

Responder(s):

Information collected through:

Record Review Teacher interview(s) Student interview Parent interview

Behavior Rating Scale(s) Direct observation Other

Specifically describe the behavior that most impedes the students learning or that of others. Safety issues should always be
addressed. What does the behavior look like and/or sound like? (Example: Physically aggressive behavior that includes
punching, slapping, kicking and spitting at others.)
Target behavior:

With what frequency, intensity, and/or duration does this behavior occur?
Frequency Intensity Duration
(How often does behavior occur?) (How severe is the behavior?) (How long does the behavior last?)

times per minute 1 2 3 4 5 seconds

hour (amount) minutes
day Low High hours
week (severity)

Other:

Notes:

Tip: Measure the target behavior tracking the frequency, intensity and/or duration prior to implementing the BISP in order to obtain an average
measurement that provides a baseline. The BISP will track the target behavior in the same way(s) as it was tracked for this FBA. It is sometimes
helpful to track a behavior using more than one method of measurement. For example, to track progress in decreasing tantrum behaviors, a team
may track frequency of tantrums as well as their intensity and duration.

Form Revised: February 14, 2012

 Name: Student ID: Date:

DOB: Age: Grade: Building/Site:

ANTECEDENTS
Describe the circumstances that are typically present BEFORE the behavior occurs.

1. What behavior(s) does the child display indicating s/he may engage in this behavior (i.e., cursing, pencil tapping,
pacing)?

Tip: In the BISP, identify these pre-cursor behaviors and include what should be done at this behavioral level to address the
situation in order to intervene as early as possible to prevent the target behavior from occurring to lessen the severity/intensity of the
target behavior. Interventions to prevent or lessen the severity of the target behavior should be considered as potential interventions
in the Prevention section of the BISP.

2. Where does the behavior occur? Indicate, for each area, whether the target behavior often, rarely or never occurs in that
location.
Location Often Rarely Never Comments
Classroom
Hallways
Cafeteria
Bus
Library
Bathrooms
Playground/Outdoor areas
Other

Tip: For those settings where the behavior often occurs, think about what common triggers might be involved. For those settings where the
behavior rarely or never occurs, think about why the behavior is more controlled in those settings. Is there any way to bring those controlling
factors into the settings where the behavior tends to occur, thereby preventing or reducing the occurrence of the target behavior? These types of
interventions should be considered as potential interventions in the Prevention section of the BISP.

3. Who is typically present and/or involved when the student displays this behavior?
Comments
Teacher
Peer(s)
Paraprofessional
School Support Staff
Counselor
Administrator
Other

Tip: Look for patterns in the persons or the behaviors of those persons typically present and/or involved. Are changes and/or supports needed to
deter the target behavior or to provide support to the others involved? These types of interventions should be considered as potential interventions
in the Prevention section of the BISP.

4. When does the behavior occur? (Is there a pattern in the time of day, day of week, type of activity, etc. when the behavior
typically occurs?) Briefly describe:

Tip: If a pattern is noted, how might the BISP address that effectively? For example, if the behavior tends to occur most often mid-morning, is it
possible that the student is hungry? If the behavior tends to occur most often right after lunch, is a more relaxing transition period needed prior to
beginning work? These types of interventions should be considered as potential interventions in the Prevention section of the BISP.

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 Name: Student ID: Date:

DOB: Age: Grade: Building/Site:

5. How is the behavior triggered and/or escalated?

Lack of social attention Independent seat work Crowded seating Negative social interaction
Demand/Request Transitions Peer attention Interruption in routine
Difficult task Group instruction Adult attention Unstructured activity
Consequences imposed for negative behavior Other:

Tip: For any items checked, think about what supports might be provided to prevent the misbehavior from occurring (including the teaching of new
behavior responses). These types of interventions should be considered as potential interventions in the Prevention and/or the Teaching Strategies
section of the BISP.
CONSEQUENCES
Describe what happens immediately AFTER the behavior occurs. (What typically happens immediately after the behavior occurs?)

Behavior ignored Time-out in the classroom In-school suspension

Redirection by teacher Communication with home Out of school suspension
Reprimand/Warning Office referral Seclusion / Restraint
Loss of privileges. Which privileges?
Time-out away from the classroom. Where?
Attention (positive or negative) from others
Other (explain):

Tip: Ask how effective the consequences have been in changing the target behavior. If the same consequences have been used repeatedly
without a change in the target behavior ask, Could this consequence be reinforcing the target behavior instead of punishing it?

HYPOTHESIS DEVELOPMENT
Based on the information gathered and summarized, what function(s) does the
identified behavior seem to serve for the student?

When the student shows the target behavior, the student seems to need:

To escape or avoid . . . To get or obtain . . .

A demand or request A desired item or activity

An activity or task Adult attention

A person or persons Peer attention

The classroom setting Control

Other Other

And / Or to communicate feelings:

Hypothesis Statement
When ,
(Contributing antecedents/consequences or conditions from student information section)

(Student) will
(Describe the target behavior what does it look like / sound like?)

in order to
(Consequences that serve as a pay off for the behavior)

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Name: Student ID: Date:

DOB: Age: Grade: Building/Site:

Therefore, the function of the behavior is to (check the one(s) that apply):

ESCAPE/AVOID:

GAIN/OBTAIN:

COMMUNICATE:

Student Information for Behavior Intervention Planning Purposes

What interventions and/or strategies are currently being used or have previously been used to address the behavior and how
has the student responded? (Provide behavioral data to support)

List the students strengths and interests:

Provide a summary of the students strengths (personal, behavioral or academic).

Name: ________________________________________________ Student ID: ________________________________ Date:

_____________________________

List any rewards, reinforcements, or incentives that work with the student:

Additional Comments:

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Name: Student ID: Date:

DOB: Age: 1 Grade: Building/Site:

FUNCTIONAL BEHAVIOR ASSESSMENT ADDITIONAL STUDENT INFORMATION

Identify additional areas and information that may play a role in this behavior.

Emotional factors:
Identify emotional factors (anxiety, depression, anger, poor self concept, etc.) that may play a role in the behavior.

Inaccurate Thought Patterns:

Identify distorted thoughts, inaccurate attributions, negative self-statements, erroneous interpretation of events that may play a role
in the behavior.

Reinforcement:
Identify environmental triggers and payoffs that may play a role in the behavior. Is there anything in the environment or any
consequences that may be reinforcing the behavior?

Modeling:
Identify the degree to which the behavior is copied, who the student models with this behavior and why the student may be copying
the behavior.

Family Issues:
Identify family issues that may play a part in the behavior.

Physiological Issues:
Identify physiological and/or personality characteristics, developmental delays/disabilities, temperament, etc. that may
play a part in the behavior.

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Name: Student ID: Date:

DOB: Age: Grade: Building/Site:

Curriculum/Instruction Issues:
Identify how instruction, curriculum, or educational environment plays a part in organizing and directing behavior.

Current instructional level:

Reading Math
Ways instruction, curriculum or the educational environment may play a part in organizing and directing behavior:

Discipline Referrals:
Summarize discipline data (classroom and office-managed referrals):

Summarize results of past assessments (behavioral and academic):

Brainstorm what might be needed to address needs and issues identified in this section?