Functional Behavior Assessment Form
Date
 -
Month
 -
Day
Year
Date
Student Name
First Name
Last Name
Student Level/Grade
Homeroom Teacher
First Name
Last Name
Strengths and unique qualities that this student brings to the school
Problem Behavior
Problem Behaviors
Tardiness
Withdrawn
Unresponsive
Aggression
Disruptive
Theft
Inappropriate Language
Verbal Harassment
Vandalism
Unable to finish the activity
Self-harm
Other
Please explain more about the problem behavior
How often does this behavior happen?
What is the duration in terms of when did it start and when did it end?
How big is this problem behavior?
Do you know what triggers the problem behavior? Is it related to tasks, activities, reprimands, or transitions?
Are the following events related to the behavior? Please select one or more:
Mistake in class
Friend conflict
Routine changes
Conflict at home
Homework
Hunger
Lack of Sleep
Medications
Other
Summary
Setting Events
Trigger
Behavior
Consequence
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