SPED 743 Completion Checklist Step 2: Conducting the Functional Assessment Team Number _15 School: KES District: Sing Date: 7/2016 5 —|—______ 2. 6. 3, 7. 4. 8. Coach or Instructor: Step 2: Condu: ing the functional assessment Directions: Complete step two, see notes in RED. Note: *Shaded rows are not required for SPED 743, but are recommended as regular prectices, Check when | Item | completed X Complete, confirm, and tum in Data collected from Informal Observatio Classroom Map; copy of PBIS plan; instructional schedule; classwide system for behavior management (Posted ) Map and Observation only a Complete, confirm, and tur in Universal Checklist HO A (Posted) o Step 2.1 Records Review Complete HO 2 and 3 SARS Forms (Posted) zg ona Step 2.2 Interviews Complete, confirm, aad turn in HO 4 Teacher Interview, including operational definition of target behavior (Posted) X Complete and confirm HO 6 FABI Planning for Target Behavior with operatioral definition [Confirmed with Coach] (do not post as this is a document in progress) X ‘Complete, confirm, and tum in HO 4 Parent Interview | (Posted) X Complete, confirm, and turn in HO 7 Student Interview (Posted) Form Updated: August 1, 2016 From Lane, K. L... & Oakes, W. P. (2014). Building efficiencies in functional assessment-based interventions: A focus on training and coaching, Manuscript in preparation.SPED 743 Completion Checklist Step 2: Conducting the Functional Assessment ‘Team Number __15, Check whem | completed a Item Step 2.3 Rating Scales Review, confirm, and tum in Social Skills Improvement System — Rating Scale (Teacher Version); Scored by Coach; Report (Post the output of the report generated by the coach, make certain this does noi any identifying information) Review, confirm, and turn in Social Skills Improvement System — Rating Seale (Parent Version); Scored by Coach; Report (Post the output of the report generated by the coach, make certain this does not any idenaifving information) Step 2.4 Direct Observation (A-B-C Data Collection) Review, confirm, and turn in HO 8 A-B-C data (data collection form); write in the number of hours (N =3) you collected A-B-C and the number of instances (N = 8 minimum) you saw the targe: behavior occur (Check that data and time are recorded), (Posted ) For SPED 743, please conduct a minimum of one hour of A-B-C data. Please remember to complete your direct observation in the setting of interest (e.g. where you will be implementing the intervention) Step 2.5 Identify the Function Write and confirm HO 6, p. 3 Funetion Matrix, include a hypothesis statement as fo what is maintaining the behavior (Posted) Complete, confirm, and tum in HO 6 FABI Planning for Replacement Behavior with operational definitions [Confirmed with Coach] (Posted } ‘Complete and tum this checklist into your instructor. (To clarify: Complete HO 6 pp. 1-3 up to function matrix and hypothesis. You will be given feedhack on your progress prior te completing subsequent pages.) Form Updated: August 1, 2016 From Lane, K. L., & Oakes, W. P. (2074). Building efficiencies in functional assessment-based interventions: A focus on training and coaching. Manuscript in preparationInterval Recording Sheet Name: Reese Date: 7/23/16 Time: 20 minutes Length of Interval: 2 minutes Target behavior: Reese often engages in off-task behavior when being told no ot not getting her way. a Date: Interval # Total times behavior occurred lps (e) 1 [2 [3 4 ]5 10 [2 20% Interval Recording Sheet Name: Reese Date: 7/24/16 Time: 20 minutes Length of interval: 2 minutes Target behavior: Reese often engages in off-task behavior when being told no or not getting her way. Date: Interval # Total times behavior oceurred Lips. 0) 1 2 | 3 [4a [5 7 [8 [9 ]10 [3 30% 1Interval Recording Sheet Name: Reese Date: 7/25/16 Time: 20 minutes Length of Interval: 2 minutes Target behavior: Reese often engages in off-task behavior when being told no or not getting her way. Total times behavior occurred Date: Interval # (x) L7ps "FETE. ™ PP fe fe fee || t| Ig i a yo a om Hose W Poee Plan Woo of 2M save a Forge ick dae ch yaw i — Fak dou ~ | Ceuch” Tt | - i i i wd OE eT a FP TU se staves omcFunctional Assessment-based Interventions (PABI) Hod Form 2.1. Preliminary Functional Assessment Interview. Positive Behavioral Support ..-for Children and their Families 2 TIME STARTED: (pC PRELIMINARY FUNCTIONAL ASSESSMENT SURVEY Instructions to PBS Staff: ‘The following interview should be conducted with the student’s teacher. Prior to the interview, ask the teacher whether or not the Classroom Aide should participate. If yes, indicate both respondents’ names. In addition, in instances where divergent information is provided, note the sources. aurea to specific information. " Student Kee ce Subject #: Age: _| Sex: M F Interviewer: Date: Respondent(s); YO VW Ce M Marek 1. List and deseribe behaviors) of concern. jolly hits tings 5 b. ©. 4. e 2. Prioritize these behaviors (which is the most important?) @ COMM \ ing FeMmper- Yc Screaming b. ~Physcality CLL PNY) - tums red Khe Operational Definition of Target chavo an a + Mamnc ay Yeh ae J or NWidha cays I ae MACWiCl “fa Kix yy locly Leeths Using ANC F spa egies. ana Tet Ei} 4 Geo! off * Jans, f 1 Exams Sie ap, Gta, berth, Wy Cake AMe Of Cay b. Source: Dunlap, G.. Kem, L., dePerezel, M., Cletke, S., Wilson, D., Childs, K. E., White, R., & Falk, G.D. (1993), Functional analysis of classroom variables for stadents with emotional and behavioral challenges. Behavioral Disorders, 18, 275-291, Reprinted with permission. 3Funetional Assessment-based Interventions (FABI) HO4 11. Does the behavior occur in response to the number of people in the immediate environment? ay olor ge pA NOP a tag XP 1OSicny, & Comfuittaine Eavirar mere e a e 12. Does the behavior occur only wich certain people? a WON Sol ad b. Siwoltags © 4. e 13. Does the behavior occur only during certain subjects? a. . \ C he DMC fo \b Man warned Jcacner PN i “ w\ K Yeacher repats i tors & Not heupper ad Schoce e 14. Could the behavior be related to any skills deficit? a aces clr way ty Calm Sell ae -mMnk b. Cie Ow WG - ) ©, Source: Dunlap, G., Kem, L., dePerezel, M., Clerke, S., Wilsoa, D., Childs, K. E., White, R., & Falk, G. D. (1993). Punetional analysis of classroom variables for students with emotional and behavioral challenges. Behavioral Disorders, 18, 275-291. Reprinted with permission. 4Functional Assessment-based Interventions (FABI) HO4 15. What are the identified reinforcers for this student? Bee ee Ne ce Mee crecion or £3 meng a Pose vier compiled bar mones Ovy wes Wer A chorvees lo tase ° Cather 4 of ao ev Ged oa © 16. Is the student taking any medication that might affect his/her behavior? a d. e 17. Could the student’s behavior be signaling some deprivation condition (e.g. thirst, hunger, lack of Test, etc.J? a wed b, « d. 18, Could the behavior be the result of any form of discomtfor blurred vision, ear infection, etc.)? (¢.g., headaches, stomachaches, Source: Dunlap, G., Kem, L., dePerczel, M., Clarke, S., Wilson, D., Childs, K. E., White, R., & Falk, G. D. (1993). Funetional analysis of classroom variables for students with emotional and behavioral challenges. Behavioral Disorders, 18, 275-291. Reprinted with permission. 5Functional Assessment-based Interventions (FABI) HO4 19. Could the behavior be caused by allergies (¢.g., food, materials in the certain environments, etc.)? e. 20. Do any other behaviors occur along with this behavior? a de Rance b. ce a. e. 21. Are there any observable events that ial the behavior of concern is about to ‘occur? @ head So re Gernande ccd She WouUtys b, c a e 22. What are the consequences when the behavior(s) occur? , Bed Candle cake Geb tater GW cu \F rnece SCevy & Goes AD coca Ye Coot off ~ulvaterter Perticgnt at Trot we « a e Comments: TIME COMPLETED: * min TOTAL TIME: ) Source: Dunlap, G., Kem, L., dePerezel, M., Clarke, S., Wilson, D., Childs, K. E., White, R., & Falk, G. D. (1993). Funetional analysis of classroom variables for students with emotional and behavioral challenges. Behavioral Disorders, 18, 275-291. Reprinted with permission. 6Funetional Assessment-based Intervertion (FAB) HOT Form 2.2. Student Functional Assessment Interview STUDENT ASSESSMENT smdent: Poe Se a Date:_]-2.Y - J Administration Time: ! DO. Target Behavior: \ 1. When do you think you have the fewest problems with (target behavior) in school? - doing dish washer clesn + mote twe Wed ‘cel . -Oong ASoTHe See Why do you not have problems dhiring this/these time(s)? Cuz Wey ‘re fliun 2. When do you think you have the most problems with (target behavior) in school? ~doing cNcres Cpe may Dog ~ GOs; % sleep ealts, eatite Why do you have problems during this/these time(s)? . UL dent want td cle them 3. What causes you to have problems with ‘target behavior)? Man doesnt terme doe sme Cade bite) ~ne y Say No 4. What changes could be made so you would have fewer problems with (anger behavion? Wt dad oh go on bike tai FACT ice Creamy 3 Source: Kern, L., Dunlap, G., Clarke, S., & Childs, K. E. (1994), Student-assisted functional assessment interview. Diagnostic, 19, 20-39. Reprinted with perm’ssion.Functionel Assessment-based Intervertion (FABI) HO7 5. What kind of rewards would you like to earn for good behavior or good-schoolwork? - buy sme - jeue Wey gun ~ Guay . ~ Eenool Shoes ice cream TOC Oa Rate how much you like the following subjects: Not Coco f Don’t like at Fair Like very all much Reading 1 2 3 4 5 Math 1 2 @ 4 5 Spelling 1 2 3 4 5 Handwriting 1 2 @ 4 5 Science I 2 3 4 SF Social 1 2 3 4 5 Studies [English T 2 3 a 3 Music 1 2 3 4 S PE. 1 2 3 4 3D Art 1 z es 4 5 What do yor like about {ACWW 2 Fe ’ Uha e Zt ge #t WY’ cna Uhat happens 1X) What do you like about_ SON. 2 get te Ieara with Mends What do you like about _\N\\AG\¢ 2 9< $ tos ng with Mendy What do you like about, 2 Get th J 2 Source: Kern, L., Dunlap, G., Clarke, S., & Childs, K. E. (1994), Student-assisted functional assessment interview. Diagnostic, 19, 20-39. Reprinted with permission.Funetional Assessment-based Intervertion (FABI) HOT What do you like about sve 2 - hanging cud lw ith Fa mily cma What do you like about Q\Owy NV 2 ploy wit Fey What don’t you like about __ We 2 hag & haw rest hme Is there any type of _(\ C’ you have ever done that you've liked? get ars Bacher fo coe fh house What could be done to improve 2 What do you like about What do you like about 2 What do you like about 2 Dunlap, G., Clarke, S., & Childs, K. E, (1994). Student-assisted functional assessment interview. Diagnostic, 19, 20-39. Reprinted with permssion.Functional Assessment-based Intervention (FAB) HO? STUDENT ASSESSMENT 2D STUDENT: _|4¢ ece DATE: \o. INTERVIEWER: — 1. In general, is your work too hard for you? always Gometimes_ never 2. In generel, is your work too easy for you? always sometimes never 3. When you ask for help appropriately, do always never you get it? — 4. Do you think work periods for cach subject (always sometimes never are too long? — —~ 5. Do you think work periods for each subject always Gometimes never are too short? ae a 6. When you do seatwork, do you do better always (sometirses never when someone works with you? — — sricktlop 7. Do you ttink people notice when you do always Coometimes GTever 4 good job? —— 8. Do you think you get the points or rewards always never you deserve when you do good work? 9. Do you think you would do better in never school if you received mare rewards? 10, In general, do you find your work always sometimes interesting? 11. Are there things in the classroom “hat always never distract you? Yong AT Monn} 12, Is your work challenging enough for you? never 6 Source: Kem, L., Dunlap, G., Clarke, S., & Childs, K. E. (1994). Student-assisted functional assessment interview. Diagnostic, 19, 2C-39. Reprinted with permission,Functional Assessment-tased Interventions (FABI) HO6 Functional Assessment and Behavior Intervention Plan: Planning Form Student Name: Reese Marek Student ID: School: KES Date of Birth: 10/12/09 Parents): Mr, and Mrs. Dave and Chris Marek Parent(s) Contact Number: _860-305-3055_ Date of Assessment: 7/25/16 Teacher Person condveting the assessment: Samantha Role: Behavior Specialist a Teacher 1 Intern X University Student o Other Identifying the Problem: Defining Target and Replacement Behaviors +: Off task, Target Behavi Operational Definition (observable, measurable, repeatable): Off-task behavior refers to any behavior that engages in activity (anger) other than what Mom or Dad says or does. Examples: Taking belly breaths, using anger avoiding strategies, taking “cool off” time Nonexamples: Hitting, yelling, crying, stomping feet Data Recording System (e.g. Event Recording, Permanent Product): Partial interval Replacement Behavior: On task Operational Definition (cbservable, measurable, repeatable): On-task behavior refers to any behavior that involves attending to parental instruction or engaging in chores (tasks). Examples: Eye contact with parents, speaking in a calm voice, using belly breaths, taking “cool off” time, using anger avoiding strategies. Nonexamples: looking away from parents, yelling, screaming, stomping feet Data Recording System (¢.g. Event Recording, Permanent Product): whole interval Rationale: Reese’s off task behavior is preventing her from caimly explaining her feelings when she doesn’t get what she wants. Baseline: During three 20 minute observation session, Reese was on- task 80% of the time. Functional Behavioral Assessment: Interviews and Direct Observations ONO Interviewees: Teacher MI Parent @% Student 1 Source: Lane, K. L., Menzies, H., Bruhn, A., & Cmobori, M. (2011). Managing challenging behaviors in schools: Research-based strategies that work. New York, NY: Guilford Press. Reprinted with permission,Functional Assessment-based Interventions (FABI) HOG Rating Scales: Hours of Total Direct Observation (A-B-C): 3 hours Setting(s) of Observations: 1) At home after dinner, 2) At home before bed Determining the Function of the Behavior: Using the Function Matrix Positive Reinforcement | Negative Reinforcement (Access Something) (Avoid Something) Attention: ABC Data: 3.2 Parent Interview: QIS: What are the identified reinforcers for this student? - Talking with peers, parents Tangibles ‘ABC Data: 1.2,2.2,3,1 ABC Data: 1.1, 1.2,2.1,22,23, Activities 3.1, 3.2 Parent Interview Parent Interview: QI5: What are the identified Q4: What do you think causes reinforcers for this student? _| (or motivates) the behavior? -2 positive choices she - Not getting her way ‘wants (different each ~ Being told ‘no” time) Student Interview: Student Interview: Q4: What changes could be —_| Q3: What causes you to have made so you would have fewer | problems with off-task behavior? problems with off-task ~ They say no behavior? - Don’t let me do stuff + Goon bike trail, get ive cream Sensory : - 2 Source: Lane, K. L., Menzies, H., Bruhn, A., de Cmobori, M. (2011). Managing challenging behaviors in schools: Research-based strategies that work. New York, NY: Guilford Press. Reprinted with permission,Funetional Assessment-hased Interventions (FABI) HO6 ] Outcome of Function Matrix: Hypothesized Function: At home after dinner and before bed, Reese engages in off-t escapes chotes or choices she doesn’t want to do. Behavioral Objective: Source: Lane, K. L., Menzies, H., Bruhn, A., & Cmobori, M. (2011), Managing challenging behaviors in schools: Research-based sirategies that work, New York, NY: Guilford Press. Reprinted with perm sion, behavior to escape activities. That is when Reese is off task, she 3Functional Assessment-based Intervention (FABD) Hos Observer: University Student Date: 7/26/16 Time start: 6:00 pm Time stop: 7:00 pm Observation Number Context Antecedent Behavior Consequence Function Session #:1 | i 2 i RM, screams "Idon’t want to” | 1M. gets no boat 11 | diners er | Mom asks RMtoclean upherdinner | Whlastomping nerfestand” | tomate iPeteioesn’t | escape acthity a elling. clean up her plate T ptnome ben Physical Turis red when tad wat 7 ok t home before i was time to get ready for bed | RM.goestobed now —_| Access/Escape 12 | bed RIM. asks Mom to go outside instead. Yells and hits the light | instead of in an hour activity switch. Observer: University Student Date: 7/27/16 Time start: 6:00 pm Time stop: 7:00 pm Observation Number Context Antecedent Behavior Consequence Function Session #: 2 A R.M says “I don’t want to right mow Mom says “pease come ish | Row.” RM runs over and says, 2a | dimmer’ a" | Magasks RM. tohelp unload the dish | Gor want to, ater my show.” | Goes to room for S minutes | escape acthity Mom says, “Come now or you're going to your room for 5 minutes.” RM. cries and yells om say Toot ong ou da 7 Athome after lo the dish washer like | asked.” Access/Escape 22 | At hom RM. asks force cream Ehistompsterteet upstans, | Mom puts RM inher oom | Actes while yelling downstairs. 23 sau forbed”® | Mom tells RM to put pajamas on (Sftng ow neuea? “MN CTVI"E | Goes to bed with no stores | Escape activity ready forbed | laying on the bed Observer: University Student Date: 7/28/16 Time start: 6:00 pm Time stop: 7:00 pm Observation Number Context Antecedent Behavior Consequence Function Session#:3 : Tilom says, "Yes, a8 soon as you do ; 3.1 | Arhome after | aM asks to go outside your chores.” BM Soesrt get reat ater | Accesvescape AM goes ouside aways and goes =| mn Mom says she would get it RM | RM doesn’t get to goin the 32 | Rlgameat | RMasks to go downstairs to get Keke and screamsruns and slams | poolin the morning forthe | Acs#¥EScape her door st 30 minutes