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

Student: __________________________________ Grade _______ Date: ____________________________

STUDENT STRENGTHS: Identify at least three strengths or contributions the student brings to school.
Academic strengths -
Social/Recreational -
Other -

ROUTINES ANALYSIS: Where, When and With Whom Problem Behaviors are Most Likely.
Time Activity & Staff Likelihood of Problem Specific Problem Current Intervention for
Involved Behavior Behavior the Problem Behavior
Low High
1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

List the Routines in order of Priority for Behavior Support: Select routines with ratings of 5 or 6. Only
combine routines when there is significant (a) similarity of activities (conditions) and (b) similarity of
problem behavior(s). Complete the FACTS-Part B for each of the prioritized routine(s) identified.
Routine 1 Problem Behavior(s)
Make description observable
Resource: Categories for Definitions of Behavior
Observable Definition:
Examples:
Non-Examples:
**If behaviors occur in more than one routine, fill out another FACTS form from this point on**

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

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

Adapted by S.Loman (2009) from C. Borgmeier (2005) ;March, Horner, Lewis-Palmer, Brown, Crone & Todd
 Contexts (Rank order strongest 3) Follow Up Questions – Get as Specific as possible
___ a. large group instruction For all: describe in detail what this context looks like: ________________
___ b. small group work ____________________________________________________________
___ c. independent work ____________________________________________________________
___ d. unstructured time ____________________________________________________________
___ e. transitions ____________________________________________________________
___ f. with peers ____________________________________________________________
___ g. with adult ____________________________________________________________
___ h. isolated/ no attention ____________________________________________________________
___ Other describe___________________________

2 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 3) Follow Up Questions – Get as Specific as possible
___ a. Academic task/demand presented If a or b - Describe task/demand in detail: ____________________
___ b. Non-Academic task/demand presented ___________________________________________________________
___ c. Adult or peer attention is diverted .
___ d. Adult or peer attention provided If c or d – What peers or what adult? What are the peer(s) or adult doing?
___ e. Access to item or activity is denied ____________________________________________________________
___ f. Access to item or activity is provided
___ Other _________________ describe_______________________ If e or f - What item or activity?__________________________________

3 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
If a, b, or c – Describe specific task/activity avoided?
___ a. Academic task is re-presented _____________________________________________________
___ b. Non-academic task is re-presented Be specific, DO NOT simply list subject area, but specifically describe type of work within the
___ c. Task is delayed, reduced or removed subject area? _________________________________________________________________
___ d. Adult or peer attention is diverted (ignore) Can the student perform the task independently? Y N
___ e. Adult or peer attention is provided Is academic assessment needed to ID specific skill deficits? Y N
___ f. Access to item or activity is denied If d or e, -- Whose attention is obtained or diverted? ______________________________
___ g. Access to item or activity is provided How is the (positive or negative) attention provided?__________________________________
___ Other, describe: ____________ Who is providing correction?____________How is it being provided?________________

If f or g -- What specific items or activities are obtained or denied? ____________________

4 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.
CONTEXT/ANTECEDENT(s) / Triggers Problem Behavior(s) CONSEQUENCE(s)/ Function
2 3
SETTING EVENTS 1 8 Escape/Attention/Tangible
4
How likely is it that this Summary of Behavior accurately explains the identified behavior occurring?
Not real sure 100% Sure/No Doubt
1 2 3 4 5 6

Adapted by S.Loman (2009) from C. Borgmeier (2005) ;March, Horner, Lewis-Palmer, Brown, Crone & Todd
Adapted by S.Loman (2009) from C. Borgmeier (2005) ;March, Horner, Lewis-Palmer, Brown, Crone & Todd