EDSP 363
FUNCTIONAL B A TEHAVIOR SSESSMENT EMPLATE
Student’s Name: Jill Smith Student’s Date of Birth: 10/5/2010
Gender: Female Date of Interview:10/5/2023
Interviewer: Respondents: General Education Teacher,
Special Education Teacher, Paraprofessional,
Jill’s parents
A. DESCRIBE THE BEHAVIORS
1. For of the behaviors of concern, define the topography (how it is performed), frequency EACH
(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. Rocking and/or
swaying
Ignoring redirection 3 to 5 days a
week
1 hour or
ongoing
through the
day
Severe –
hitting peers
and knocking
into them
while rocking
b. Slapping leg Striking leg with an
open hand,
accompanited by
yelling, swaying, or
vocalizing
2-4 times per
day
5-10 minutees Severe –
hitting peers
and knocking
into them
while rocking
c. Crying When someone
inadvertently bumps
into her desk, this
disrupts her regular
routine, leading to
screaming until her
needs are addressed
2-4 times a
day
Until she
vacates the
area or
someone
provides her
with
assistance
Mild –
Attention
seeking
d. Withdrawn Seems distant,
unwilling to engage in
conversation
After each
occurrence of
behavior, 2-4
times a day
Continues to
increase in
duration with
each behavior
Severe –
Affecting her
mental state
e. Vocalizations Crying,
rocking/swaying,
slapping with open
hand
2-4 times a
day
10 minutes to
an hour
Mild – No
self harming
f. Screaming Rocking aggressively,
slapping self,
screaming “no, no
Jill!”
2-4 times a
