Functional Behavioral Assessment (FBA) Form

Structured school-based form to document antecedents, observable behaviors, consequences, and suspected function to support development of a behavior intervention plan for a student receiving special education services.

Assessment Context and Consent

• Student Name
  Enter the student's full name for record matching.
• Student ID
  Optional school identifier if needed for internal record matching.
• Grade Level
• Assessment Date
  Date the FBA is being completed.
• Assessor Name
  Name of the staff member completing this form.
• Reason for Assessment
  Briefly describe the behavior concern and why the FBA is being completed.
• Consent / Disclosure Acknowledgement
  Confirm that any required notices, consent, or disclosure steps have been handled according to school policy and applicable law.

Target Behavior Definition

• Target Behavior Name
  Short label for the behavior being assessed.
• Operational Definition of Behavior
  Describe exactly what the behavior looks and sounds like. Avoid vague terms such as 'disruptive' or 'defiant' without observable details.
• Behavior Type
  Select all behavior categories that apply.
• Baseline Frequency
  Approximate number of occurrences per day, week, or class period if known.
• Baseline Duration
  If known, describe how long the behavior typically lasts (for example, '5-10 minutes').
• Behavior Intensity

Antecedents and Setting Events

• Antecedents / Triggers
  Select the events or conditions that occurred immediately before the behavior.
• Setting Events
  Select any broader factors that may have influenced the behavior.
• Antecedent Narrative
  Describe the situation leading up to the behavior, including task demands, environment, and adult prompts.
• Location
  Where the behavior occurred, if relevant.
• Time of Day

Behavior and Consequence Details

• Behavior Description
  Describe the behavior as observed, using objective language.
• Number of Occurrences
  How many times the behavior occurred during the incident or observation period.
• Duration
  How long the behavior lasted, if known.
• Immediate Consequence
  Select what happened right after the behavior.
• Consequence Narrative
  Describe the response from staff, peers, and the environment after the behavior occurred.

Function Hypothesis and Team Plan

• Suspected Function of Behavior
  Select the most likely reason the behavior is occurring based on the available data.
• Evidence Summary
  Summarize the patterns or observations that support the suspected function.
• Replacement Behavior to Teach
  Describe the skill or alternative behavior the student should be taught to use instead.
• Recommended Supports
  Select supports to consider in the behavior intervention plan.
• Follow-Up Date
  Date for team review or next meeting.

Submission and Audit Trail

• Submitted By
  Name of the person submitting the form.
• Role
• Additional Notes
  Include any other relevant observations, team decisions, or documentation notes.