Functional Assessment Worksheet

Triggers:

• cue by teacher
• less structured class time
• verbal instructions
• independent work
• class discussion
• SSR
• class instruction
• start of class
• cleanup
• cooking
• hands-on activity
• done with work
• transition time

Behavior:

• off task
• talking out
• negative peer interaction
• not following teacher instructions
• negative physical peer interactions
• aggressive acting out behavior
• disruption of class
• impulsive behavior
• refusal to work
• rude comments
• not following class routines
• not following safety rules

Purpose:

• avoid a demand or request
• avoid an activity or task
• get out of class
• get desired activity or item
• gain student attention
• gain adult attention
• appear inadequate
• fear of failure
• self-stimulation
• power struggles
• gain control of the class
• compulsion
• revenge

Consequences:

• time out
• verbal cue
• class removal
• negative peer response
• loss of privileges/incentives
• positive peer response

Statement:

When (trigger) occurs, the student does (behavior) in order to (purpose). The consequence of this behavior is typically (consequence).

Behavior Specialist Teacher Interview

Date_____Teacher__________School_______
Student Name__________Grade_____IEP: Yes No

Situations

Problem Behaviors

Expected Behaviors

1. What is the most common strategy that you have tried/used?

2. How long did you try this strategy?

3. What has been the most effective strategy?

4. Is there anything that you have tried that you want to try again?

What consequences have you tried for the problem behavior?

• loss of privileges
• time out
• referral to school counselor
• note or phone call home to student's parents
• detention
• meeting with the student's parents
• office referral
• reprimand
• individual meeting with the student
• Other

What have you tried to teach expected behaviors?

• reminders about expected behavior when problem behavior is likely
• reward program for expected behavior
• systematic feedback about behavior
• clarified rules and expected behavior for the whole class
• oral agreement with the students
• individual written contract with the student
• practiced the expected behaviors in class
• self management program
• contract with the student's parents
• Other

What have you tried to change the situations in which the problem behavior(s) occur?

• modified assignments to match student's skills
• arranged tutoring to improve student's academic skills
• changed seating assignments
• changed curriculum
• changed schedule of activities
• provided extra assistance
• OTher