Functional Behavior Assessment Date:

Section I: Description Child:

Data Sources: ! Observation | ! Student Interview | ! Parent Interview Assessed by:

Description of the behavior

Setting(s) in which the behavior occurs

Frequency of behavior

Duration of behavior

Consequences to peers, staff members, or instructional environment

Descriptions of or references to previous interventions

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Functional Behavior Assessment Date:
Section II: Analysis of Function Child:
Check the hypothesized function(s) for the behavior and describe Assessed by:

! Gain attention

! Gain a tangible consequence

! Gain a sensory consequence

! Escape from or avoidance of an undesirable situation

! Affective regulation / emotional reactivity

! Make a comment or declaration

! Release tension

! Fill a habitual need

! Other

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Functional Behavior Assessment Date:
Section III: Behavioral Intervention Plan Child:
Assessed by:

Expected Outcomes / Interventions &

Intervention Review Notes
Replacement Behaviors Frequency of Interventions
Person Responsible

Review Dates

1 ______________

1
2 ______________

3 ______________

4 ______________

Person Responsible

Review Dates

1 ______________

2
2 ______________

3 ______________

4 ______________

Person Responsible

Review Dates

1 ______________

3
2 ______________

3 ______________

4 ______________

Person Responsible

Review Dates

1 ______________

4
2 ______________

3 ______________

4 ______________

polyxodotcom
Copyright 2001, Jason M. Wallin Version 1.0
Oak Harbor, Washington
Teaching Children with Autism
http://www.polyxo.com/

The latest version of this document is available at http://www.polyxo.com/documents/