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From Ron Taylor, Assessment of Exceptional Students, Fifth Edition. Copyright © 2000 by Allyn & Bacon. Used with permission. Further use of this material is prohibited without written permission from the publisher. The publisher’s website address is abacon.com/education/home.html.

Appendix D

Functional Behavior Assessment Form

FUNCTIONAL BEHAVIOR ASSESSMENT

Part One: Assessing the Behavior

1. Specific Target Behavior (include topography; include frequency, duration, or intensity)

2. Setting(s) in Which Behavior Occurs

3. Activities during Which the Behavior Occurs

4. Time of Day Behavior Occurs

5. Person(s) Around Whom the Behavior Occurs

6. Factors That Appear to Set Off or Precede the Behavior

Teacher Factors Task Explanation Performance Feedback Lesson Presentation Teacher Reprimand Teacher Praise Individual Attention Lack of Attention Task Demands Teacher Request Consequence Imposed for Negative

Behavior Other

Peer Factors Peer Attention (Positive) Peer Attention (Negative) Other

Setting Factors Transition (Task; Routine) Transition (Setting; Routine) Transition (Task; Unexpected) Transition (Setting; Unexpected) Elevated Noise Levels Presence of Unfamiliar Adults Presence of Unfamiliar Peers Other

7. Factors That Appear to Be Present When the Behavior Occurs

Student Factors Drowsy/Sleepy Appearance Physical Complaints (e.g., hunger, pain) Disturbed Affect ( e.g., sad, angry) Excessive Motor Activity Other

Setting Factors Independent Seat Work Group Instruction Crowded Setting One-to-One Instruction Unstructured Setting Unstructured Activity Other

8. Factors That Appear to Follow the Behavior

Teacher Factors Teacher Reprimand Teacher Praise Task Removal Withdrawal of Attention Teacher Warning Time-Out Response Cost Sent to Office Communication with Parent Predetermined Contingency Imposed In-School Suspension Out-of-School Suspension Other

Peer Factors Peer Attention (Positive) Peer Attention (Negative) Other

9. Behavioral Intent or Function(s) That the Behavior Appeared to Serve

Power Control Over Teachers Over Peers Over Parents Other

Escape/Avoidance From an Activity/Task From a Person From the Classroom From the School

Other Attention

Teacher Peer Parent Other

Expression of Self Gratification (Self-Reward) Acceptance/Affiliation (More Formal Than Immediate Peer Attention) Justice/Revenge Other

Part Two: Formulation of Hypotheses

Based on Information from Part One:

1. What Appears to Be the Predominant Setting/Activity in Which the Behavior Occurs?

2. What Time(s) of Day Does the Behavior Typically Occur?

3. Around What Person(s) Does the Behavior Typically Occur?

4. What Seems to Immediately Precede or Set Off the Behavior?

5. What Seems to Be the Immediate Consequence of the Behavior?

6. What Function or Purpose Does the Behavior Seem to Serve?

Functional Hypothesis

Indicate both (a) the conditions in which the behavior occurs and (b) the function that the behavior seems to serve.

Part Three: Development of Behavior Intervention Plan

Prevention of Behavior

Based on the available information, list steps that could be taken to prevent the target behavior from occurring (e.g., avoidance of certain tasks and/or types of instructional delivery, searing arrangement)

Replacement Behavior

Based on the available information, what behavior needs to be taught to allow the student to have a successful adaptation (e.g. requesting assistance to replace tantruming as a means of gathering attention)

Identification of Reinforcers

List all reinforcers, including preferred activities that are appropriate for this student

Implementation of Behavior Intervention Plan

Goal

Prevention Strategies for Target Behavior

Strategy Date Person(s) Responsible Outcome

Intervention Strategies for Replacement Behavior

Strategy Date Person(s) Responsible Outcome

Criteria for Program Discontinuation