FBA Observation and summary Form (FBA-osF)

Student: ________________________ Observer: ___________________________

Class/ Date /
Behaviors Antecedents Consequences Location Time
(write in) (write in)
Behavior Incident #

Interaction
Class Activity
Task Level

Obtain

Avoid/
Escape
Alone / No attention

Peer Attention

Peer Attention
Unstructured

Task/Activity

Task/Activity
instruction

With Peer(s)
Teacher-led

With Adult

Attention

Attention
Seatwork
Difficult

Tangible

Tangible
Adult

Adult
Long

Date:

Date:

Date:
Easy

time

FBA-OSF Page 1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
TOTAL

Directions: For each behavior incident, place an X in the appropriate boxes across the corresponding row to indicate which behaviors, antecedents, and consequences were observed. After
all observations are completed, create a summary statements that describes the antecedents and consequences that are most closely related to each behavior and build an intervention plan
using this summary. A template for writing summary statements can be found on page 2 of this form.
Adapted with permission from the Functional Assessment Observation Form (O’Neill, Horner, Albin, Sprague, Storey, & Newton, 1997); (c) 2012 Oxford University Press, Inc. For
personal use only. From Filter, K. J. & Alvarez, M. E. (2012). Functional behavior assessment: A three-tiered prevention model. New York, NY: Oxford University Press.
 Summary Statements from FBA Observation

Response Class #1

Antecedent Behavior Consequence

Response Class #2

Antecedent Behavior Consequence

FBA-OSF Page 2
Response Class #3

Antecedent Behavior Consequence

Directions: For each behavior incident, place an X in the appropriate boxes across the corresponding row to indicate which behaviors, antecedents, and consequences were observed. After
all observations are completed, create a summary statements that describes the antecedents and consequences that are most closely related to each behavior and build an intervention plan
using this summary. A template for writing summary statements can be found on page 2 of this form.
Adapted with permission from the Functional Assessment Observation Form (O’Neill, Horner, Albin, Sprague, Storey, & Newton, 1997); (c) 2012 Oxford University Press, Inc. For
personal use only. From Filter, K. J. & Alvarez, M. E. (2012). Functional behavior assessment: A three-tiered prevention model. New York, NY: Oxford University Press.