SOUTH LYON COMMUNITY SCHOOLS

62500-B Nine Mile Road

South Lyon, MI48178

Functional Behavioral Assessment

Date

/ Student Name / Birthdate / Grade / Attending Bldg.

FBA Participants in Attendance:

Name/TitleName/Title

______

______

______

______

______

______

FBAResources:

____ Record Review (CA60)

____ Behavior Logs / Discipline Reports

____ Structured Interviews w/______

____ Reports from ______

____ Rating Scales ______

____ Observation by ______

____ Student narrative

____ Other ______

PROBLEM IDENTIFICATION

Describe the BEHAVIOR(s) of concern (observable and measurable) ______

______

______

______

Justification for Intervention: (check all that apply)

___ Behavior results in harm to student or others ___Behavior results in substantial property damage

___ Behavior impedes learning ___ Behavior results in exclusion/suspension

Baseline Data:

How frequently does the behavior occur? (ex: 2/day; 5/wk) ______

How long does the behavior last once it occurs (duration)?______

How INTENSE is the behavior when it occurs? LOW 12345 HIGH

Isolated pattern of behavior-explain ______

How does the student explain behavior? ______

Student Name:______Date: ______

PROBLEM SPECIFICATION

Relevant History
Summarize historical information that may be relevant in interpreting the individual’s behavior.
General History (Family; Personal: Likes/Dislikes; Strengths/Challenges; etc)
Medical Issues/Treatment (including diagnoses (medical / psychiatric), medications (purpose / dosage), and service agencies / medical professionals currently involved)
Educational Programs / Related Services (Previous services as well as current)
Social History (including interaction with peers and adults, family members, family issues, etc.)
Intervention History (including treatments / strategies attempted and their affect on the behavior
Behavior History (How long has the behavior been a problem? Have there been other behavior challenges?

Antecedent / Setting Events

What is happening before the behavior occurs? ______

______

Where does the behavior occur MOST often?______LEAST often?______

At what time of day does the behavior occur MOST often?______LEAST often?______

Who is student with when behavior(s) occurs? ______

______

Explain what happens as a consequence of the behavior? ______

______

______

What positive interventions have been tried? ______

______

______

Do positive interventions diminish behavior? ______Explain. ______

______

Attach Student Statement if available9/06

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