Student Name_________________________Date__________________Completed by_______________

Table A: Functional Behavioural Assessment

Setting Events Antecedent Triggers Problem Behaviour

In Classroom With Adults Inattention

□ Group activity
□ Independent sent work
□ Teacher-directed activity
□ Transitions
□ Change in staff
□ Less-structured times
□ Specific subject area (i.e.
gym, math)
Out of Classroom
□ Before/after school
□ Break times
□ Hallways/bath-room
□ Bus
□ Family issues
□ Peers issues
□ Community issues
Other
□ Time of day
□ Physiological factors (i.e.
illness, allergies, hunger,
pain, lack of sleep,
medication, drug use)
END
□ Teacher request
□ Teacher demand
□ Reprimand or correction
□ Lack of immediate
teacher response
□ Difficult task
□ Unclear/long task
□ Interruption of task
□ Extended seat work
□ Change of routines
□ Transitions
□ Conflict at home
□ Conflict at school
With Peers
□ Alone (no attentin)
□ Social isolation
□ Social Alienation
□ Verbal interaction
□ Non-verbal interaction
□ Physical interaction
□ Conflict with peers
□ Conflict in the
Community
Other
□ Unpredictable events (i.e.
fire alarm,
announcements
□ Extreme weather
condition
END
□ Inattentiveness
□ Distractible
Non-Compliance/
Defiance
□ Oppositional
□ Argumentative
□ Disruptive
□ Passive aggressive
Inappropriate
Vocalization
□ Laughing inappropriately
□ Teasing Making disruptive
noises
□ Arguing/talking back with
adult
□ Arguing with student
□ Impulsive responses
Inappropriate Movement
□ Fidgeting in seat
□ Walking around classroom
□ Use material
inappropriately
□ Motoric restlessness
□ Jumping out of seat
□ Running around class
□ Clinging to teacher
□ Sitting/standing beside
desk
□ Impulsive behaviour
CONTINUED
Problem Behaviour Problem Behaviour Consequences
Strategies

Repetitive Movements Anxiety-related Behaviour Maintaining

Consequences/
Function
□ Finger/pencil tapping □ Tantrums or anger out- Get/Obtain
□ Foot tapping/swinging burst □ Adult attention
□ Spinning an object □ Extreme emotional □ Peer attention
□ Rocking reactions □ Desired item or activity
□ Hand flapping/waving □ Oversensitivity □ Sensory stimulation
□ Pacing □ Excessive worry □ Personal power or control
□ Talking/humming to self □ Obsessive thoughts □ Other
□ Other self-stimulation □ Anxious or nervousness
□ Compulsive behaviours □ Withdrawn
□ Dramatic mood swings Escape/Avoid
Social Issues □ Pervasive mood of □ Certain task or activity
□ Social isolation or alienation unhappiness □ Difficult or dull tasks
□ Poor peer relations □ Low frustration □ Staff requests/demands
□ Peers conflict tolerance □ Teacher reprimand(s)
□ Extreme attention-seeking □ Irritability and agitation
behaviours □ Teacher correction
□ Repetitive ritualized □ Loss of personal power
□ Lying or deceitful behavior behaviour(s) □ Embarrassment/humiliation
□ Shortness of breath □ Negative consequences
Verbal Aggression □ Perfectionism □ Failure
□ Use of profanity □ Required reassurance □ Sensory overload
□ Name-calling □ Fight/flight behaviour □ Social interaction
□ Harassment □ Slower behaviour in □ Peer or adult attention
□ Disrespectful and/or rude gestures order to complete tasks □ Other
□ Threatens or intimidates other well
□ Avoidance of tests
Self-Injurious Behaviour Physical Aggression
□ At-risk behaviours to safety of □ Kick/hitting/throwing
self objects
□ Threats of self-harm □ Pushing/fighting
□ Hitting/biting/self-mutilation □ Destructive to property
□ Suicidal ideation □ Theft
□ Drug/alcohol abuse
□ Sexual promiscuity Somatisation
□ Sleeping/head down
□ Complaints of physical
symptoms
 Table B: Positive Behaviour Support Plan
Setting Event
Preventive Strategies Teaching strategies Consequence Strategies
Strategies
□ Structured setting with □ Provide short breaks □ Give clear, concise □ Praise, reassurance and
consistent between assignments instructions encouragement
consequences
□ Allow student to stand □ Use direct □ Frequently compliment
□ Develop a model of at times while working questioning and positive behaviour and
classroom behaviour restatement to clarify work product
management that is □ Allow opportunity for
clear in its physical movement □ Seek to involve □ Use teacher attention to
expectations – e.g. student in lesson reinforce positive
□ Provide opportunity presentation
consequences/reward for “seat breaks”, i.e. □ Set predictable intervals of
□ Maintain a user- run errands, etc □ Break tasks into “no work” periods that the
friendly environment manageable child may earn as a reward
□ Use quiet desk or area sequential steps for effort
to reduce frustration to help refocus
□ Maintain a low stimuli □ Shorten assignments □ Acknowledge positive
□ Give reminders when or work periods to behaviour of nearby
environment problem behaviour is coincide with span of student
□ Strategic seating near likely to occur attention
instructional area □ Increase immediacy of
□ Practice expected □ Adapt lessons and rewards and consequences
□ Proximity control behaviour assignments
□ Ignore minor inappropriate
□ Seat in quiet area □ Prompt appropriate □ Provide one-on-one behaviour
behaviour verbally or instruction for new
□ Seat near good role private signal or difficult tasks □ Use close-ended choices
model
□ Set up behavioural □ Peer tutoring □ Direct questioning and
□ Seat near “study goals and implement restatement to refocus or
buddy” reward program □ Provide alternative redirect
tasks when
□ Increase distance □ Use behaviour assignment precedes □ Use of privileges or
between desks contract acting-out response cost

□ Supervise closely □ Look for signs of stress □ Use multi-sensory □ Use of restitution
during transition times build up and provide approach
reassurance □ Use time out or time away
□ Encourage cooperative □ Assist student in to help refocus
learning tasks with □ Speak softly and setting short term
other students calmly □ Identify problem behaviour
goals and ask for it to “Stop”,
□ Use daily agenda to □ Student-teacher □ Have student assist wait for compliance
communicate between discussions others in areas of
home and school □ Praise compliant behaviour
academic strength
□ Send positive notes home
□ Home support □ Use relaxation □ Use contracting with □ Use a behaviour
program to provide techniques student for work modification program
supervised homework completion
time □ “Greet & Meet” with □ Counselling intervention
student daily prior to □ Instruct student in
□ Send daily/weekly school to diffuse any self-monitoring of □ Administrative
behaviour reports issues behaviour using cues involvement
home □ Contact parents
□ Reinforce frequently □ Pair written
□ CEA support when when signs of instructions with oral
possible frustration are noticed instructions

□ Look for signs of □ Modify assignments

frustration and reduce to match student
work load to alleviate skills
pressure
□ Provide extra
□ Learn to identify body assistance
signals of
stress/frustration □ Supervise writing
down of homework
□ Develop skills to de- assignments
escalate stressful
situations □ Class discussions
focusing on social
□ Provide training in self- interactions e.g.
control; use calming social curriculum
strategies; tell nearby
adult if becoming □ Encourage
stressed cooperative learning

□ Assign special □ Encourage peer

responsibilities to monitoring
student in presence of □ Provide small group
peer social skills training
□ Reduce overall
expectation for
flexibility and
frustration tolerance
(e.g. identify critical
situations, tasks,
interactions)