Functional Assessment Checklist for Teachers and Staff (FACTS-Part A)

Student: Grade Date:

Staff Interviewed: Interviewer:
ROUTINES ANALYSIS: Where, When and With Whom Problem Behaviors are Most Likely.
Time Routine/Activity & Likelihood of Problem Specific Problem Current Intervention for
Staff Involved Behavior Behavior the Problem Behavior
Low High
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PRIORITIZED ROUTINE: Select a routine with a rating of 5 or 6. Only combine routines when there is
significant similarity in (1) activities (conditions) and (2) problem behavior(s). Complete the remainder of
this page and FACTS-Part B for the prioritized routine identified below.
Routines/Activities/Context Problem Behavior(s)
Prioritized
Routine
**If 3 or more routines are rated a 5 or 6, refer case to behavior specialist for a Complex FBA**

Functional Assessment Checklist for Teachers & Staff (FACTS-Part B)

STUDENT STRENGTHS: Identify at least three strengths or contributions the student brings to school.
Academic strengths -
Social/Recreational -
Other -
BEHAVIOR(s): Rank order the top priority problem behaviors occurring in the targeted routine above:
___ Tardy ___ Fight/physical Aggression ___ Disruptive ___ Theft
___ Unresponsive ___ Inappropriate Language ___ Insubordination ___ Vandalism
___ Self-injury ___ Verbal Harassment ___ Work not done ___ Other ________________
Describe prioritized problem behavior(s) in observable terms: _______________________________
_____________________________________________________________________________________

What is the frequency of the Problem Behavior in the targeted routine (# x’s /day or hour)?
What is the duration of the Problem Behavior in the targeted routine (in seconds or min)?
Is Behavior Immediate Danger to Y N
self/others? If Yes, refer case to Behavior Specialist for a Complex FBA

Adapted for Basic FBA to BIP by C. Borgmeier & S.Loman (2016) from March, Horner, Lewis-Palmer, Brown, Crone & Todd, 1999)
Last revised 12/14/2017
 Functional Assessment Checklist for Teachers & Staff (FACTS-Part B)
Specify the Target Routine: Use the prioritized routines from FACTS-Part A for assessment.
Routine/Activities/Context & Staff Name Problem Behavior(s) – make description observable

ANTECEDENT(s): Rank Order the strongest triggers/predictors of problem behavior in the routine above.
Then ask corresponding follow-up question(s) to get a detailed understanding of triggers ranked #1 & 2.
Environmental Features (Rank order strongest 2) Follow Up Questions – Get as Specific as possible
___a. task too hard ___g. large group If a,b,c,d or e - describe task/demand in detail ___________
___b. task too easy instruction _________________________________________________
___c. bored w/ task ___h. small group work If f - describe purpose of correction, voice tone, volume etc.
___d. task too long ___i. independent work _________________________________________________
___e. physical demand ___j. unstructured time If g, h, I, j or k - describe setting/activity/content in detail
___f. correction/reprimand ___k. transitions _________________________________________________
___Other ______________ ___l. with peers If l – what peers? __________________________________
Describe ______________ ___m. isolated/no attention If m – describe -
CONSEQUENCE(s): Rank Order the strongest pay-off for student that appears most likely to maintain the
problem behavior in the routine above. Then ask follow-up questions to detail consequences ranked #1 & 2.
Consequences/Function As applicable -- Follow Up Questions – Get as Specific as possible
___ a. get adult attention If a or b -- Whose attention is obtained?
___ b. get peer attention How is the (positive or negative) attention provided?
___ c. get preferred activity
___ d. get object/things/money If c, d, e, or f -- What specific items, activities, or sensations are obtained?
___ e. get sensation
___ f. get other, describe________ If g or h- Describe specific task/activity/sensation avoided?
_________________________ Be specific, DO NOT simply list subject area, but specifically describe type of work
___ g. avoid undesired activity/task within the subject area?
___ h. avoid sensation
___ i. avoid adult attention Can the student perform the task independently? Y N
___ j. avoid peer attention Is academic assessment needed to ID specific skill deficits? Y N
___ k. avoid/escape other, describe If i or j – Who is avoided? _____________________________________
_________________________ Why avoiding this person?

SETTING EVENT(s): Rank Order any events that happen outside of the immediate routine (at home or earlier in
day) that commonly make problem behavior more likely or worse in the routine above.
__ hunger __ conflict at home __ conflict at school __ missed medication __ illness __failure in previous class
__ lack of sleep __change in routine __ homework not done __ not sure __ Other___________________________
SUMMARY OF BEHAVIOR
Fill in boxes below using top ranked responses and follow-up responses from corresponding categories above.
ANTECEDENT(s) / Triggers Problem BEHAVIOR(s) CONSEQUENCE(s)/ Function
Routine:
Trigger:

SETTING EVENTS

How likely is it that this Summary of Behavior accurately explains the identified behavior occurring?
Not real sure 100% Sure/No Doubt
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Adapted for Basic FBA to BIP by C. Borgmeier & S.Loman (2016) from March, Horner, Lewis-Palmer, Brown, Crone & Todd, 1999)