Functional Behavior Assessment (FBA) Template

📊 Assessment Progress Tracker

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📋 Part 1: Identifying Information

Student Name *

Date of Birth

School

Grade

Assessment Date *

Assessor Name *

Reason for Referral *

📚 Part 2: Background Information

Educational History

Medical/Health Information

Current Supports & Services

IEP

504 Plan

Speech Therapy

Occupational Therapy

Physical Therapy

Counseling

Behavioral Support

Other

Previous Interventions Attempted

🎯 Part 3: Problem Behavior Identification

⚠️ Define Behaviors in Observable, Measurable Terms

Include what the behavior looks like, sounds like, and how it can be measured.

Target Behavior	Operational Definition	Frequency/Duration	Intensity

Behavior History

📈 Part 4: Assessment Methods & Data Collection

Data Collection Methods Used *

Direct Observation

ABC Recording

Scatterplot Analysis

Frequency Data

Duration Recording

Interviews

Rating Scales

Record Review

Data Collection Timeline

Week 1

Week 2

📝 Part 5: ABC Data Analysis

ℹ️ Record Multiple Instances

Document at least 5-10 instances of the target behavior to identify patterns

Date/Time

Antecedent (What happened before?)

Behavior (What exactly occurred?)

Consequence (What happened after?)

ABC Pattern Summary

🌍 Part 6: Environmental & Setting Analysis

When is the behavior MOST likely to occur?

When is the behavior LEAST likely to occur?

Environmental Factors

Noise Level

Crowding

Lighting

Temperature

Seating Arrangement

Peer Proximity

Adult Proximity

Materials/Resources

Setting Events (distant factors that may influence behavior)

💡 Part 7: Functional Analysis & Hypothesis

✅ Hypothesis Statement

Primary Function Hypothesis *

Supporting Evidence

Alternative Hypotheses

⭐ Part 8: Student Strengths & Preferences

Student Strengths

Preferred Activities/Items

Preferred People

Learning Style

📋 Part 9: Summary & Recommendations

Assessment Summary *

Recommended Interventions

Environmental Modifications

Antecedent Strategies

Teach Replacement Behavior

Reinforcement System

Response Strategies

Skill Teaching

Home Collaboration

BIP Development

Specific Intervention Recommendations

Next Steps

👥 Part 10: Assessment Team

Team Member	Role/Title	Contribution to Assessment	Contact Information