Student Functional Behavior Assessment Interview Form - South Bend Community School Corporation

ADVERTISEMENT
South Bend Community School Corporation
Special Education Department
 
Student Functional Behavior Assessment Interview
Student:
School:
Grade:
Date of Birth:
Age :
Interviewer:
Date Completed:
Directions: To complete this survey, it is recommended that each question be read to the student in an informal
manner. While you should guard against pressuring a student to complete each statement, please be
sure to follow-up or clarify any vague responses.
Section A
Always
Sometimes
Never
1. In general, is your work too hard for you?
2. In general, is your work too easy for you?
3. When you ask for help appropriately, do you get it?
4. Do you think work periods for each subject are too
long?
5. Do you think work periods for each subject are too
short?
6. When you do seatwork, do you do better when
someone works with you?
7. Do you think people notice when you do a good job?
8. Do you think you get the points or rewards you deserve
when you do good work?
9. Do you think you would do better in school if you
received more rewards?
10. In general, do you find your work interesting?
11. Are there things in the classroom that distract
you?
12. Is your work challenging enough for you?
13. Do you think you can concentrate on schoolwork?
14. Do you get along well with your classmates?
8/6/10
South Bend Community School Corporation
Special Education Department
 
Student Functional Behavior Assessment Interview
Student:
School:
Grade:
Date of Birth:
Age :
Interviewer:
Date Completed:
Directions: To complete this survey, it is recommended that each question be read to the student in an informal
manner. While you should guard against pressuring a student to complete each statement, please be
sure to follow-up or clarify any vague responses.
Section A
Always
Sometimes
Never
1. In general, is your work too hard for you?
2. In general, is your work too easy for you?
3. When you ask for help appropriately, do you get it?
4. Do you think work periods for each subject are too
long?
5. Do you think work periods for each subject are too
short?
6. When you do seatwork, do you do better when
someone works with you?
7. Do you think people notice when you do a good job?
8. Do you think you get the points or rewards you deserve
when you do good work?
9. Do you think you would do better in school if you
received more rewards?
10. In general, do you find your work interesting?
11. Are there things in the classroom that distract
you?
12. Is your work challenging enough for you?
13. Do you think you can concentrate on schoolwork?
14. Do you get along well with your classmates?
8/6/10
 
Section B
When do you think you have the fewest problems in school?
Why do you not have problems during this/these time(s)?
When do you think you have the most problems in school?
Why do you have problems during this/these time(s)?
What changes could be made so that you have fewer problems with this behavior?
Section C
What do you like and/or dislike about:
Like
Dislike
Reading
Math
Spelling
Handwriting
Science
Social Studies
English/Language
Music
Physical Education
Art
Other (specify):
7/18/16
 
Section D
Who lives with you in your home?
Always
Sometimes
Never
1. Do you worry a lot about problems at home?
2. Do you do chores at home?
3. Do you sleep at least 7 hours each night?
4. Do you eat at least three meals a day?
5. Do you take your prescribed medications at home?
6. Do you think your prescribed medication helps you?
7. Do you get along well with your parents and siblings?
8. Do you experiment with drugs and alcohol?
9. Do you have friends in your neighborhood?
7/18/16

Download Student Functional Behavior Assessment Interview Form - South Bend Community School Corporation

451 times
Rate
4.3(4.3 / 5) 27 votes
ADVERTISEMENT
Page of 3