Applied Sciences Signature Assignment

Functional Behavior Assessment (FBA) EDUU 695: Signature Assignment Template

Note: Names and identifying information have been changed to protect the client’s confidentiality.

Demographics
Client’s Name: Please use a pseudonym
Client’s DOB:	Client’s Age:
Parent/Guardian Name(s): Responsible Party Name(s): (pick one of the 2 depending on the age of the client)	Relationship to Client:
Primary Language:	Living Arrangement:
Current Providers: (list health care or other service providers) Name: Role: Name: Role: Name: Role:

REASON FOR ASSESSMENT

(This is the reason for referral as presented by referring person or agency)

SOURCES OF ASSESSMENT DATA (You can use bullet points or a table)

Records Reviewed:

· Record name (Date)

· List additional records, as needed

Interviews:

· List people interviewed and the date conducted

Observations:

All observations were conducted by your name. The total observation time frame was XX/XX/2023-XX/XX-2023.

List Setting (ex. General education classroom or Family Home):

· Dates and times of observations. Also total time

· Example: 4/14/2023 8:00 a.m.-9:30 a.m. (90 min)

Assessment Tools:

Choose one below based on the questionnaire used

· The Functional Analysis Screening Tool (FAST)

· Questions About Behavior Function Tool (QABF)

Indicate the interview form if you used one

· The Functional Behavior Assessment Interview (FBAI)

Indicate the ABC Analysis Form you used. For example:

· Structured ABC (Antecedent-Behavior-Consequence) Analysis Form

Or

· Narrative ABC (Antecedent-Behavior-Consequence) Analysis Form

Add additional tools, if used. This may include standardized assessments, reinforcer surveys, etc.

BACKGROUND INFORMATION

Client Description:

Write a concise summary of the client’s demographic information including early history, current living situation, birth history, known trauma and medical history.

Educational & Intervention History:

Write a concise summary of relevant intervention or educational experiences including intervention.

Client Strengths:

Write a concise description of the client/child’s strengths as determined by the different assessments, interviews and observations that were conducted as part of the intake. Be sure to reference where the information came from.

Client Preferences:

Write a description of child likes, interests and preferences as determined by the different assessments, interviews and observations that were conducted as part of the intake. Be sure to reference where the information came from. E.g. did you complete a preference assessment, complete a reinforcer survey, etc.

Findings

Indirect Assessments

Summarize your interviews and your questionnaire results (FAST or QABF). Feel free to include a graph of questionnaire results (e.g., bar graph), but it is not required. Provide some detail about what interviewees said or what was relevant on questionnaires provided to interviewees.

Behavior of Concern

Based on interviews and past records of problem behavior, the following behavior was selected to be addressed to by this FBA.

Problem Behavior (e.g., elopement): provide an operational definition

Direct/Descriptive Assessments

· Provide a summary of your direct observations including;

· A representative statement/description of your observations. You do not need to summarize each observation, but provide some detail of where you were to conduct the observations, who was present, what was observed.

· Summarize your ABC data narratively.

· Include a table with representative observations.

· Include a bar graph of consequent events only (see Blackboard for sample)

· Include a graph of baseline data you collected (e.g., frequency/rate, duration, latency, etc.)

· Discuss the findings from your Functional Assessment Observation Form, if it adds to or is different from your other data sets

· Include your hypothesis statement, this should be based on your analysis. )

(Here is a sample table you can use)

Antecedent, Behavior, Consequence Data on XXX Behavior
Date/Period	Antecedent	Behavior	Consequence	Function
9/15/22	Provided math worksheet and instructed to transition from his computer game	Refusal to Transition	Continued access to preferred item Delay in task/ escape	Access to tangible/Escape
9/17/22	Playing computer game and was prompted to go to recess	Refusal to Transition	Continued access until the computer was turned off	Access to tangibles
Add in each recorded event

Sample hypothesis statement:

Results from all direct and indirect assessments combined indicate that the function of task refusal behavior is escape. During the initial clinical interview Mrs. Mother stated that the maladaptive behaviors generally followed the presentation of a non-preferred task or the placement of a demand. The FAST questionnaire supported this as the results also indicated that the potential source of reinforcement is socially mediated with a function of escape from tasks and activities. The FAST also suggested that there may have been a secondary function of attention or preferred items, however, this was not supported by direct assessments. Based on the ABC data that was collected during the initial direct observation, task refusal behavior was preceded by the placement of a demand or transition to a non-preferred activity, indicating that the function of the behavior was escape. During the following functional observations, the perceived function of task refusal was also escape for all 19 episodes of the behavior. Assessment results indicate that when Child is presented with a demand or non-preferred task, she engages in task refusal by vocal protesting, screaming, running away, turning away and crying, which is followed by the removal or the demand or task. Therefore, the hypothesized function of task refusal is escape.

Functional Analysis Assessment (FAA)

Setting

Describe the setting where the FA took place. Include where the room was located, what the room looked like, what was in it, etc.

Procedures

Put in enough detail so that someone else would be able to replicate what you did.

Add a line graph representing your data. See example below.

Findings

This includes your visual analysis of the graph (remember level, trend, variability). Be sure to confirm or disconfirm your hypothesis statement.

References

At minimum you will be referencing the Cooper book.

Appendix

Include:

· Functional Assessment Observation Form (from PENT)

· Any assessment protocols you have not submitted (optional)

· Data samples (ABC, baseline, scatter plot)

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