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Form 7a - Functional Behavioral Assessment Page 1 August 2008

PURPOSE: A Functional Behavioral Assessment (FBA) is used to gather information about a students behavior to determine the need
for, and provide the foundation for, a Behavioral Intervention Plan (BIP). An FBA is required to be conducted if the students violation
of a code of conduct (resulting in a change of placement) is determined to be a manifestation of the students disability.


FUNCTIONAL BEHAVIORAL ASSESSMENT

Student name: Jia Qi Ng Meeting Date:
Student ID #: Disability: Autism Grade: K
Home School: Broadview Thompson K-8 Case Manager:


Team Members Present at Meeting:


Name/Title

Name/Title

Name/Title

Name/Title

Name/Title

Name/Title

Students Strengths (include a description of the students behavioral strengths, such as positive interactions with staff, ignoring the
inappropriate behavior of peers, accepts responsibility, etc.):
- Activities of daily living such as toileting routines, dressing, and cleaning
- Curiosity about others
- Savvy about school routines and procedures
- Attention to details such as wiping up small spills on cafeteria cloor
Description of Behavior(include a description of the frequency, duration, and intensity of the behavior(s)):
- Runs out of classroom during unstructured times, transitions, and times when not engaged or interested in an
activity
- Sometimes complies with redirections, other times resists redirections
Setting(s) (include a description of the setting(s) in which the behavior occurs, i.e. physical setting, time of day, persons involved):
- Classroom
- School hallways
- Playcourt
Antecedent(s) (include a description of the relevant events that preceded the behavior):
- Requests to return to classroom from preferred activity
- Transition times
- Activity that is non-preferred or perceived of as too challenging
Form 7a - Functional Behavioral Assessment Page 2 August 2008
Consequences and Educational Impact (include a description of the result of the behavior (i.e. removed from class, not
able to complete assignments/tests, etc.), and the impact on the student, peers, and the instructional environment):
- Miss instructional time and community building opportunities
- Disruptive to learning environment
Other Potential Variables (include a description of any other factors/variables that may affect the behavior, such as medication,
weather, diet, sleep, substance abuse, attendance, social factors, etc.):
- New classroom, people, and routines in a familiar school building
- Sensory overload in noisy classroom
- Instructional demands not appropriate- requests too long for receptive language ability
Prior Interventions (include a description of the behavioral interventions that have been implemented in the past, including the
date(s) of implementation, length of intervention, the impact of the intervention on the students behavior, etc. Attach data summary, if
appropriate):
- Tokens
- Reminders
- Rewards of preferred activities such as music
- Visual of behavior expectations
- Food reinforcement
Hypothesis of Behavioral Function (describe the teams hypothesis of the relationship between the behavior and the
environment in which it occurs what function is this behavior serving for the student? What is the student trying to get? What is he/she
trying to avoid?):
- Avoid or escape non-preferred activities in order to engage in preferred activities such as walking, running,
and sensory experiences

Summary/Recommendations (Provide recommendations for prevention of the target behavior, replacement skills/behavior(s)
to be taught, reinforcements for positive behaviors, etc.):
- Replacement Behavior: Pull on adults hand to indicate desire to leave the classroom and go on a walk