FBA Worksheet

Functional Behavioral Assessment (FBA)

Steps to Conducting an FBA within

the Context of the Evaluation
or Reevaluation Process
 FBA Worksheet

STEP 1: FBA INTERVIEW

Student Name: Date:

School: Grade: DOB:
Educational Program Description:

Instructions: When the answer checked is YES, add details on the lines provided.

List strengths of the student (such as academic, social, physical, family assets):

Description of the Behavior of Concern (specifically describe what the behavior looks and sounds like):

Physiological and Medical Factors:

1. Could the behavior be the result of a medical or psychiatric condition or any form of physical discomfort?

¨ NO ¨ YES

2. Could the behavior be related to a side effect of medication?

¨ NO ¨ YES

3. Could the behavior be the result of some physical deprivation condition (thirst, hunger, lack of rest, etc.)?

¨ NO ¨ YES
 FBA Worksheet

Antecedent Events:

1. Are there circumstances in which the behavior ALWAYS occurs?

¨ NO ¨ YES

2. Are there circumstances in which the behavior NEVER occurs?

¨ NO ¨ YES

3. Does the behavior occur only (or more often) during particular activities?
¨ NO ¨ YES

4. Does the behavior occur only with (or more likely with) certain people?
¨ NO ¨ YES

5. Does the behavior occur in response to certain stimuli (demands, termination of preferred activities, tone of
voice, noise level, ignoring, change in routine, transitions, number of people in the room, etc.)?
¨ NO ¨ YES

6. Does the behavior occur only (or more likely) during a certain time of day (morning, afternoon, end of
school day, evening)?
¨ NO ¨ YES

Skill Deficits Related to Behavior of Concern:

1. Could the behavior be related to any skill deficits? (check all that apply*)

o Academic Skills: Task requirements as presented are not at the student’s instructional level in the core
areas of Reading, Math, or Writing.

o Participation Skills: The student has difficulty with participating in non-directed, semi-directed,
teacher-directed, or peer-directed activities. The student has difficulty in small or large group
instruction.

* If checked, please refer for further assessment (i.e. Speech & Language evaluation, Occupational Therapy evaluation, curriculum-
based assessments, specific skills assessments).
 FBA Worksheet

o Social Skills: The student has difficulty acquiring and/or maintaining peer friendships. The student
often withdraws from social interaction. The student is often verbally and/or physically aggressive in
social interactions.

o Communication Skills: The student has difficulty requesting what he/she needs, including items,
activities, attention, information, changes in the environment, or help. He/she has difficulties in
conversational skills and answering questions, understanding nonverbal or verbal language, or
following directions.

o Organizational Skills: The student has difficulty organizing school supplies, study area, time or
projects, organizing class notes, or dividing assignments into tasks.

o Self-Regulation Skills: The student has difficulties staying on-task; completing work assignments;
handling stressful situations; calming self when agitated; following rules; or difficulty transitioning
between activities, places, or people. The student has difficulty with problem solving.

o Study Skills: The student has difficulty studying for tests, taking tests, taking notes from lectures, or
using studying techniques.

o Motor Skills: The student has difficulty with gross motor skills (e.g., running, raising arms, putting
feet together, squatting, bending at waist) or fine motor skills (e.g. pointing, counting with fingers,
holding a pencil/pen, holding a fork/spoon, pressing a computer key, using a mouse. The student has
difficulty imitating others’ actions.

o Functional Skills: The student has difficulty performing activities of daily living (e.g., eating,
dressing, toileting, grooming).

o Play Skills: The student has difficulty actively exploring activities/toys in their environment (inside or
outside) to play with during leisure time, playing with the items as designated, or engaging in
interactive play with peers during activities.

Consequence Factors:

1. Does the behavior allow the student to gain something?

A. Preferred activities or items?

Indicators: The behavior often occurs when the student sometimes or always regains an item or activity that
has been taken away or terminated. The behavior often occurs when the student sometimes or always gains
access to an activity or item that the student was told he/she couldn’t have. The behavior rarely occurs
when the student is given free access to his or her favorite items or activities.
¨ NO ¨ YES

B. Peer or adult attention?

Indicators: The student frequently approaches others. The student frequently initiates social interaction.
When the behavior occurs, someone usually responds by interacting with the student in some way (e.g.,
verbal reprimand, redirection, comforting statements). The behavior rarely occurs when the student is
receiving attention.
¨ NO ¨ YES
 FBA Worksheet

2. Does the behavior allow the student to postpone, avoid, or escape something such as task demands, social
interaction, etc.?

Indicators: The behavior often occurs when the student sometimes or always postpones or escapes the task
demands placed upon him. The behavior rarely occurs when few demands are placed on the student or when the
student is left alone. The student is often noncompliant when asked to complete tasks, and the student sometimes
or always postpones or escapes the tasks. The behavior often occurs prior to predictable demands and the student
sometimes or always avoids or postpones the tasks.
¨ NO ¨ YES

3. Does the behavior provide stimulation as an alternative to the student’s lack of active engagement in activities?
¨ NO ¨ YES

Indicators: The behavior occurs frequently when the student is alone or unoccupied. The student seems to have
few known reinforcers or rarely engages in social interaction activities. When the student engages in the behavior,
others usually respond by not attending to the behavior.
¨ NO ¨ YES
 FBA Worksheet

STEP 2: DIRECT OBSERVATION

The FBA interview results in a measurable description of the behavior of concern and information that leads to
direct observation with data collection and analysis

Direct observation:

• Serves to clearly define the behavior

• Supports or refutes interview information
• Allows for assessment of behavioral events in the student’s natural environment
• Leads to a hypothesis regarding the function(s) of the student’s behavior of concern
• Serves as a baseline to measure the frequency, duration, and/or intensity of the behavior prior to
intervention
• Provides information that is necessary to build a Positive Behavior Support Plan (PBSP)
• Supplies the team with progress monitoring data to evaluate the implemented interventions and guide
adjustments to the PBSP

Data collection process:

• Define the behavior in observable and measurable terms

• Determine the purpose for data collection—the type of information needed from each data collection
session (e.g. frequency counts, identifying antecedents and/or consequences)
 FBA Worksheet

• Outline the schedule including where, when, how often, and who will collect data
• Design tools with clear coding systems that will result in the collection of the type of data needed and that
are functional
• Transfer the data to a visual representation (graph) and analyze it for trend, level, and variability
• Analyze data regarding behavior of concern, antecedent events, and maintaining consequences to determine
the function of behavior. Use this information to identify replacement behaviors and behavioral
interventions, and develop a PBSP. An annotated Positive Behavior Support Plan and blank PBSP are
available on the PaTTAN website (www.pattan.net). Under Evidence-Based Practices, Select Behavior →
Select Publications .
• Utilize progress monitoring data to evaluate the implemented interventions and guide adjustments to the
PBSP

Data collection methods:

• Record frequency and/or duration indicating time of day, location, activities occurring, and people present
• Write a description of the student’s behavior as well as the antecedents and consequences using the
Antecedent Behavior - Consequence (A-B-C) format. This type of data must be collected multiple times
across settings when the behavior of concern occurs as well as when the behavior of concern does not
occur.

The following data collection tools, including sample forms are available on the PaTTAN website (www.pattan.net).
Under Evidence-Based Practices, Select Behavior → Select Publications.
• Functional Assessment Observation Tools (Appendix A)
• Functional Assessment Interview Forms (Appendix B)
• Functional Assessment Secondary Team Forms (Appendix C)
 FBA Worksheet

STEP 3: SUMMARY

List strategies used in the past and note their effectiveness:

Antecedent (prevention) strategies: Consequence strategies:

Direct Observation Summary (attach graphic representation of observation data collected)

1. Describe how often the behavior of concern occurs, how long it lasts, and at what intensity it occurs.

2. Describe any patterns to the occurrence of the behavior of concern (consider the time of day, location, and
others involved).

Antecedent and Consequence Factors

1. Describe the antecedents that are present when the behavior of concern occurs.

2. Describe the consequences that appear to be maintaining the behavior of concern.

Hypothesis Regarding Function of the Behavior of Concern (The team may identify more than one hypothesis.)

1. When (antecedent to behavior of concern) , (student)

(behavior of concern) in order to (perceived
function of the behavior) .

2. When (antecedent to behavior of concern) , (student)

(behavior of concern) in order to (perceived
function of the behavior) .
 FBA Worksheet

COMMONWEALTH OF PENNSYLVANIA
Edward G. Rendell
Governor

DEPARTMENT OF EDUCATION
Gerald L. Zahorchak
Secretary

Diane Castelbuono
Deputy Secretary Office for Elementary and Secondary Education

John J. Tommasini
Director Bureau of Special Education

Patricia Hozella
Assistant Director Bureau of Special Education

11/09