H Perry EDLC 623
F BUNCTIONAL EHAVIOR ASSESSMENT TEMPLATE
Student’s Name: Jill Smith
Student’s Date of Birth: 5/17/2011
Gender: Female
Date of Interview: 10/1/23
Interviewer: Mary Hanna Perry
Respondents: Mr. and Mrs. Smith, Ms. Right,
Jill’s Gen Ed teacher, Mrs. South, Jill’s SLP and
Mrs. Middle, Jill’s paraprofessional
A. DESCRIBE THE BEHAVIORS
1. For EACH of the behaviors of concern, define the topography (how it is performed), frequency
(how often it occurs per day, week, or month), duration (how long it lasts when it occurs), and
intensity (how damaging or destructive the behaviors are when they occur).
Behavior
Topography
Frequency
Duration
Intensity
a. Dislike of the
cafeteria
When in school, Jill
is instructed by her
teacher to get ready
for lunch. Instead
she will sit and stare
at her desk.
Every day since it
has gotten colder
and the students are
unable to eat
outside.
The behavior
usually stops once
Jill is removed
from the cafeteria,
but it is taking
longer and longer
for Jill to get back
to baseline.
Extreme
b. Swaying/rockin
g while
humming
This happens at
school when Jill
does not want to do
something she is
asked to do.
Multiple times a
day, especially in
general large group
instruction
The situation
usually resolves
once Jill is removed
from the activity or
given another
choice.
Moderate - it is
disruptive and
happens multiple
times a day.
c. Distant, seems
to be in her
own space,
easy to agitate
This happens both
at home and at
school.
Often.
This started right
around Jill’s second
birthday.
Moderate
d. Jill will not
sleep due to
night terrors
At home, especially
when she’s had an
upsetting day or an
item is missing from
her collection.
When an item is
missing or Jill’s had
a bad day.
Hours to an entire
night
Moderate
e. Hits herself in
the head on
