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1342.12 Companion
July 12, 2017
Page 141
Functional Behavioral Assessment Report
Part 1 (Description)
Student Name:
DOB:
Grade:
Written By:
Data Source:
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Parent Interview
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Teacher Interview
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Student Interview | Interviewed By: _________________________ | Date of Interview: ___________
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Records Review
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Rating Scales
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Normative Testing
Description of Behavior
(Include Frequency, Intensity, and Duration)
Triggers
(i.e., Difficult Task, Transition, Demand/Request, Peer Interaction, etc.)
Concurrent Events or Setting
(i.e., Independent Seatwork, Adult or Peer Attention, Unstructured
Setting, etc.)
Consequences
(Note if this appears to increase or decrease the behavior, i.e., Behavior Ignored,
Reprimand/Warning, In-School Suspension, Sent to Office, Communication with Parent, etc.)
Describe Previous and Current Behavioral Interventions and Results
Describe Previous Modification(s) to Program and Results
(i.e., Changes in programming, schedule,
class section, and addition or deletion of IEP goals and objectives)