FBA – PAGE 6
FUNCTIONAL BEHAVIORAL ASSESSMENT
PROBLEM BEHAVIOR QUESTIONNAIRE
Name: / Birthdate: / Grade: / Date:
Class/Location: / School: / Completed by:
Teacher of record and/or appropriate staff identify observable problem behavior(s).
Student Behavior - One
Considering a typical episode of the problem behavior, circle the frequency at which each of the following statements are true.
Almost Always / Sometimes / Almost Never
  1. Does the problem behavior occur and persist when you make a request to perform a task?
/ 1 / 2 / 3 / 4
  1. When the problem behavior occurs do you redirect the student to get back on task or follow the rules?
/ 1 / 2 / 3 / 4
  1. When the problem behavior occurs do peers verbally respond or
/ 1 / 2 / 3 / 4
laugh at the student?
  1. Does the problem behavior occur to get your attention when you are working with other students?
/ 1 / 2 / 3 / 4
  1. Does the problem behavior occur in the presence of specific peers?
/ 1 / 2 / 3 / 4
  1. Does the problem behavior occur duringspecificacademicactivities?
/ 1 / 2 / 3 / 4
State Activity:
  1. Does the problem behavior stop when peers stop interacting with
/ 1 / 2 / 3 / 4
the student?
  1. If the student engages in the problem behavior, do you provide one-to-one instruction to get the student back on task?
/ 1 / 2 / 3 / 4
  1. Is the problem behavior more likely to occur following unscheduled events or disruptions in the class routine?
/ 1 / 2 / 3 / 4
  1. If behavior is observed at any other time or circumstance than mentioned above, please specify below.
/ 1 / 2 / 3 / 4
FBA – PAGE 7
Student Behavior - Two
Teacher of record and/or appropriate staff identify observable problem behavior(s).
Considering a typical episode of the problem behavior, circle the frequency at which each of the following statements are true.
Almost Always / Sometimes / Almost Never
  1. Does the problem behavior occur and persist when you make a request to perform a task?
/ 1 / 2 / 3 / 4
  1. When the problem behavior occurs do you redirect the student to get
/ 1 / 2 / 3 / 4
back on task or follow the rules?
  1. When the problem behavior occurs do peers verbally respond or laugh at the student?
/ 1 / 2 / 3 / 4
  1. Does the problem behavior occur to get your attention when you are
/ 1 / 2 / 3 / 4
working with other students?
  1. Does the problem behavior occur in the presence of specific peers?
/ 1 / 2 / 3 / 4
  1. Does the problem behavior occur during specific academic activities?
/ 1 / 2 / 3 / 4
State Activity:
  1. Does the problem behavior stop when peers stop interacting with the
/ 1 / 2 / 3 / 4
student?
  1. If the student engages in the problem behavior, do you provide one-to-one instruction to get the student back on task?
/ 1 / 2 / 3 / 4
  1. Is the problem behavior more likely to occur following unscheduled
/ 1 / 2 / 3 / 4
events or disruptions in the class routine?
  1. If behavior is observed at any other time or circumstance than mentioned above, please specify below.
/ 1 / 2 / 3 / 4
FBA – PAGE 8
STUDENT BEHAVIOR - THREE
Teacher of record and/or appropriate staff identify observable problem behavior(s).
Considering a typical episode of the problem behavior, circle the frequency at which each of the following statements are true.
Almost Always / Sometimes / Almost Never
1. Does the problem behavior occur and persist when you make a request / 1 / 2 / 3 / 4
To perform a task?
2. When the problem behavior occurs do you redirect the student to get / 1 / 2 / 3 / 4
back on task or follow the rules?
3. When the problem behavior occurs do peers verbally respond or laugh / 1 / 2 / 3 / 4
at the student?
4. Does the problem behavior occur to get your attention when you are / 1 / 2 / 3 / 4
working with other students?
5. Does the problem behavior occur in the presence of specific peers? / 1 / 2 / 3 / 4
6. Does the problem behavior occur during specific academic activities? / 1 / 2 / 3 / 4
State Activity:
7. Does the problem behavior stop when peers stop interacting with the / 1 / 2 / 3 / 4
student?
8. If the student engages in the problem behavior, do you provide one-to-
one instruction to get the student back on task? / 1 / 2 / 3 / 4
9. Is the problem behavior more likely to occur following unscheduled
events or disruptions in the class routine? / 1 / 2 / 3 / 4
10. If behavior is observed at any other time or circumstance than mentioned
above, please specify below. / 1 / 2 / 3 / 4

FBA – PAGE 9

STUDENT BEHAVIOR – FOUR
Teacher of record and/or appropriate staff identify observable problem behavior(s).
Considering a typical episode of the problem behavior, circle the frequency at which each of the following statements are true.
Almost Always / Sometimes / Almost Never
1. Does the problem behavior occur and persist when you make a request to / 1 / 2 / 3 / 4
perform a task?
2. When the problem behavior occurs do you redirect the student to get back / 1 / 2 / 3 / 4
on task or follow the rules?
3. When the problem behavior occurs do peers verbally respond or laugh at / 1 / 2 / 3 / 4
the student?
4. Does the problem behavior occur to get your attention when you are working / 1 / 2 / 3 / 4
with other students?
5. Does the problem behavior occur in the presence of specific peers? / 1 / 2 / 3 / 4
6. Does the problem behavior occur during specific academic activities? / 1 / 2 / 3 / 4
State Activity:
7. Does the problem behavior stop when peers stop interacting with the / 1 / 2 / 3 / 4
student?
8. If the student engages in the problem behavior, do you provide one-to-one / 1 / 2 / 3 / 4
instruction to get the student back on task?
9. Is the problem behavior more likely to occur following unscheduled events / 1 / 2 / 3 / 4
or disruptions in the class routine?
10. If behavior is observed at any other time or circumstance than mentioned / 1 / 2 / 3 / 4
above, please specify below.
Additional Comments:

FBA_Problem_Behavior_Quest8 / 2004