Functional Behavioral Assessment Summary

  Incomplete Incomplete
 
Student   Date(s) of FBA data collection
 
Date of incident Date of incident Staff conducting FBA
 
Behavior resulting in this FBA
 
Date of manifestation determination Date of manifestation determination  (required in addition to FBA if expulsion is considered)
 

 
Behavior frequency Behavior frequency behavior has occurred only one time   behavior has occurred multiple occasions
 
The behavior has now resulted in: Cum. Suspension < 10 days/yr
  Recommendation for 45-day alternate placement
  Recommendation for expulsion
 

 
Analysis of this behavior was based on:
 
interviews with  
 
observations on  
 
review of records, consisting of:   health discipline other
 

 
  Hypothesis of function of this behavior for this student  
 
 
 
Analysis of why this is the probable function
 
If unclear, state why
 
  FBA has identified these current predictors or triggers for this behavior and these consequences the student achieves by this behavior (antecedent and consequence analysis)  
 
 
 

 
Estimate of need for behavioral support: Estimate of need for behavioral support: extreme serious moderate needing attention, early state intervention
  monitoring of behavior only - no formal behavior plan is deemed necessary at this time
 
Rationale
 
  What factors in the school environment and/or instruction and/or interactions should be altered to prevent the behavior from reoccurring (which will be presented to IEP team for inclusion in a behavior plan)  
 
 
 

 
Any other recommended additional services to address the problem behavior? goals/objectives to be developed in IEP
 
(next IEP date and goal areas)
 
  in-school services for inclusion in IEP: (next IEP date and recommended services)  
 
 
  off-campus agencies or communication provision (recommended services or communication exchanges and IEP meeting date)  
 
 
  services for parents to be discussed at IEP meeting (recommended services and IEP date)  
 
 
  other service or communication provision (recommended services or communication exchanges and IEP meeting date)  
 
 
  Recommended environments where behavior plan should be used (to be presented to IEP team)  
 
 

 
Results of FBA
 
See IEP dated See IEP dated     for the Behavior Support Plan which will be developed to address behavior analyzed in this Functional Behavioral Assessment. This plan describes what staff will do to support alternative behavior. If this behavior required an FAA (CA Ed. Code for serious behavior: assaultive, self-injurious, severe property damage or other pervasive maladaptive behavior) and a Positive Behavioral Intervention Plan is recommended, see IEP dated see IEP dated    for full data analysis and PBIP or: if no plan is to be developed and established by  the IEP on the IEP on , complete the following:
 
  If a behavior support plan is NOT developed as a result of this assessment, the IEP team's final rationale  
 
 
 
The IEP team has determined that if a behavior plan is NOT to be developed as a result of this assessment, a formal behavior support plan will be developed if
 
Problem behavior continues or escalates
 
Date of IEP Date of IEP  in which behavior goals to monitor future behavior will be (or have been) developed: