"Functional Behavioral Assessment (Fba) Form" - Broward County, Florida

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Download "Functional Behavioral Assessment (Fba) Form" - Broward County, Florida

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School Board of Broward County, Florida
FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA)
Last Name:
__________________________
First Name:
________________
Today’s Date:
_________________
DOB:
_____________________________
Grade:
___________________
Student ID#:
_________________
School:
_____________________________
Dates Reviewed:
____________ ____________ ___________ _________
Exceptionalities:____
________ _________
In Attendance:
Name
Title
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
Rationale
The student is engaging in behavior that places them or others at risk of harm and/or results in substantial property damage.
Behavioral concerns may result in exclusion from participation in activities or settings with peers.
The educational team is considering a more restrictive placement due to behavioral concerns.
The student’s behavioral difficulties persist despite consistently implemented behavior management strategies based on
a less comprehensive or systematic assessment
Other:
____________________________________________________________________________________________
Student Profile
A.
Describe the student’s strengths, skills and interests:
B.
Describe the student’s limitations:
Target Behavior
What is the specific behavior identified for increase or decrease?
Description of behavior (What does the student say or do?)
Baseline Estimate (how often, how long)
Records What records were reviewed?
curriculum/IEP
disciplinary records
previous interventions
anecdotals/home notes
psychological evaluation
other:
What relevant information was obtained?
Conducted by:
__________________________________________________
School Board of Broward County, Florida
FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA)
Last Name:
__________________________
First Name:
________________
Today’s Date:
_________________
DOB:
_____________________________
Grade:
___________________
Student ID#:
_________________
School:
_____________________________
Dates Reviewed:
____________ ____________ ___________ _________
Exceptionalities:____
________ _________
In Attendance:
Name
Title
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
___________________________________________________
______________________________________________
Rationale
The student is engaging in behavior that places them or others at risk of harm and/or results in substantial property damage.
Behavioral concerns may result in exclusion from participation in activities or settings with peers.
The educational team is considering a more restrictive placement due to behavioral concerns.
The student’s behavioral difficulties persist despite consistently implemented behavior management strategies based on
a less comprehensive or systematic assessment
Other:
____________________________________________________________________________________________
Student Profile
A.
Describe the student’s strengths, skills and interests:
B.
Describe the student’s limitations:
Target Behavior
What is the specific behavior identified for increase or decrease?
Description of behavior (What does the student say or do?)
Baseline Estimate (how often, how long)
Records What records were reviewed?
curriculum/IEP
disciplinary records
previous interventions
anecdotals/home notes
psychological evaluation
other:
What relevant information was obtained?
Conducted by:
__________________________________________________
School Board of Broward County, Florida
FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA)
Last Name:
_________________________
First Name:
________________
Today’s Date:
_________________
DOB:
__________________________
Grade:
_________
Student ID#:
_________________
School:
__________________________
Dates Reviewed:
_________ __________ __________ ____________
Indirect Assessments
What interviews were conducted?
student
parent
ESE teacher
general education teacher
school administrator
related services provider
other interviews:
other indirect assessments:
Conducted by:
____________________________________________
Direct Assessments
What data was collected?
Data Collected:
Date(s):
Conducted by:
A-B-C
Scatter plot(s)
Frequency
Duration
Latency
Other:
Other:
What relevant information was obtained:
Setting Events
Are there other variables that appear to be affecting the student’s behavior (e.g., medical problems, curricular
issues?
Summary (Hypothesis) Statements
Patterns
What patterns were identified in the data collected? (i.e., circumstances in which the behavior is most likely/least likely;
possible functions of the behavior)
When this occurs:
the student does
to get, or avoid
(describe the circumstances)
(describe the behavior)
(describe consequences)
Based on the FBA:
Interventions to be implemented:
A Positive Behavioral Intervention Plan (PBIP) will be developed
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