Functional Assessment Worksheet

Triggers:

Behavior:

Purpose:

Consequences:

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?

What have you tried to teach expected behaviors?

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