1234 School Address

Pretty City, CA 12345

Ph. 555-444-4444
Fax. 555-555-5555
School Website

CONFIDENTIAL
FUNCTIONAL BEHAVIOR ASSESSMENT (FBA) REPORT
Name: Grade:
Birth Date: School:
Chronological Age: Ethnicity:
Report Date: Testing Date(s):
Name of Assessor:

The following assessment report may contain sensitive information subject to misinterpretation. Nonconsensual
disclosure by unauthorized individuals is prohibited by both the California State Education Code and the Welfare
and Institution Code.

A note on the use of the template:

This document is a template and is not intended to be used a sample report. Items in red are included as guidance
for each section only. Therefore, all items in red are to be removed in the final assessment report. To allow ease of
understanding for all IEP participants, information presented in this template should be written in paragraph
format instead in lieu of bullet points, whenever possible. Parent friendly language is strongly recommended. Not
all sections of the report are required, therefore removal of sections is recommended depending on the individual
assessment for the student for whom it was completed.

Reason for Referral

The purpose of this assessment is to gather data on target behavior in order to identify the function of the target
behavior, including the identification of setting events, antecedents and consequences that may evoke or support
the occurrence of the target behavior. If appropriate, recommendations made as a result of this assessment will
guide supportive educational and behavioral strategies within a Behavior Intervention Plan (BIP). This information
may also be utilized to support the IEP team to determine the most appropriate and least-restrictive setting to meet
the student’s needs.

 Must include, but may not be limited to:

o Source of referral (teacher, parent, SST, related services provider, etc.).
o Include general description of problem (target) behaviors.
o If using the terms used by parents or teachers use “”=”quotes” (e.g. “aggression” or “task
refusal”).
o If the target behaviors have been present in the past, include documentation of when the
behavior was first observed, as well as patterns of observable behavior which may justify the
need for assessment.
o If there is available data from previous BSPs, include a graph to show worsening or improvement
in target behaviors over time.

NAME: DOB: REPORT DATE:

Confidential Functional Behavior Assessment Report page 1
 Background Information

Sources Used to Gain Background Information

X Cumulative Records
Statewide Academic Assessment Records
Discipline Records
X Attendance Records
Academic Progress/ Report Cards
X Interview/ Questionnaire (Parent, student, teacher)
X Previous IEPs and Progress Towards Goals
Previous Psychoeducational Evaluation Reports

Educational history:
 History of schools attended
 Attendance information
 History of retention?
 Environmental, cultural, and economic information:
o Foster home or Licensed Children’s Institution (LCI) residence
o Family members with whom the student now resides
o Home Language
o Family goals for student’s performance in the home, school, and community
o Probation/Juvenile court involvement
o Department of Child and Family Services (DCFS) Involvement
 Indicate the student’s:
o Academic and personal strengths
o Brief statement of academic need (more listed below as related to behavioral incidents)
o History of academic and behavioral needs/incidents (documented in school records)
 IEP History:
o Note changes in:
 Behavior Intervention Plan outcomes
 Behavior goals
 Eligibility
 Related services
 Instructional setting

 Health and developmental information (update from the previous assessment if appropriate):
o Any health issues that might impact learning or behavior
o A medical diagnosis of (DSM criteria) is noted (where information is) by (doctor) on (date)
o Relevant medication information and why prescribed
o Exchange of information form for (doctor) was received on (date) by school
o Vision and hearing information (if updated)
o Outside health reports, if applicable

Behavioral History

 Narrative of areas of behavioral need

o History of specific behavior(s) documented in school records with references
o Frequency, duration and intensity of each behavior

NAME: DOB: REPORT DATE:

Confidential Functional Behavior Assessment Report page 2
  Discipline history
o Office Discipline Referrals (ODR)
o Suspensions or expulsions
o Include a graph, if there is available data, to visually show the occurrence of problem behaviors
over time.
 Brief discussion on current achievement history to document impact of behavior on access to curriculum:
o Indicate the current curriculum
o Report card information
o Current work samples and classroom test performance

Intervention History

 Include historical intervention attempts. For each documented intervention, report on the following:
o Beginning and end dates of each intervention
o Problem behavior(s) targeted by the intervention
o Proposed function of the behavior
o Alternative behaviors targeted for increase
o Parent communication/participation
o Additional staff support provided?
o Are behaviors currently included in a BIP and/or behavioral goal in the IEP?
 Was there a behavior change due to implemented intervention?
o Indicate whether the intervention(s) was/were successful or not in reducing the problem
behavior
o Use charts (line graph) and refer to the charts when reporting on effectiveness of interventions
 Previous FBA’s, include:
o Reason for assessment
o Target behaviors
o Frequency, duration and other data
o Function of the behavior
o Recommendations and outcomes

Current Functional Behavior Assessment

Evaluation Procedures:
Assessment procedures are selected so as not to discriminate on the basis of gender, culture, language, ethnicity or
disability. This is an assessment of an English language learner (ELL). Materials and procedures were provided in
the student’s native language/mode of communication in a form most likely to yield accurate information
regarding the student’s current levels of functioning. Any exceptions to the above will be addressed in the following
report. The following procedures were components of this evaluation: List any Standardized or Criterion
Referenced Rating Tools/Instruments used in the assessment. Current items listed in red are for guidance purposes
only.

Parent Input:
 Interview
 Rating Scales and Questionnaires
Student Input:
 Interview
 Reinforcement Survey
 Rating Scales and Questionnaires
Educational Team Input:
 Cumulative Records Review

NAME: DOB: REPORT DATE:

Confidential Functional Behavior Assessment Report page 3
  Observation of the Student
 List complete name of assessment: list assessor if not the individual writing the report
o Rating Scales and Questionnaires: completed by Ms. Teacher Extraordinaire
Observation and Data Collection
If formal observation or data collection tools were used, include name and version here i.e. frequency data,
duration, scatterplot, or antecedent-behavior-consequence (ABC) data

Student Interview

Enter any narrative interview, assessment or rating scale data here (reinforcement survey data is in a future
section)

Parent and Teacher Interviews

I. Target Behaviors
o Description of problem/target behaviors reported by the teacher and the parent
o Frequency, duration and intensity of each target behavior identified
o Use the information in section I to complete the following table:

Target Behavior How often does it occur Duration Intensity

II. Antecedents
o For each target behavior identified in section (I) of the report, identify:
 Immediate antecedents that most likely evoke the problem behavior
 Example of immediate antecedents, i.e. asking to perform a specific task, interruption
of specific activities, denied access to specific items or activities, or lack of attention
o Times when the problem behavior most and least likely to occur
o Settings where the problem behavior most and least likely to occur
o People with whom the problem behavior is most and least likely to occur

III. Possible Maintaining Consequences:

o For each target behavior identified in section (I) of the report, identify:
 First list the problem behavior and then describe the following:
 What do the adults do in reaction to the problem behavior (e.g. the teacher might
prompt the student to engage in appropriate behaviors, if the teacher is using Green,
Yellow, or Red stop light might move the student down into red, might reprimand the
student, might send the student to the office)
o What happens to the behavior after the adult’s actions following the behavior? Does the
behavior stop right after the adult interferes or continues?

IV. Setting/Environmental Factors Effecting Problem Behavior

o For readability purposes, include a statement to describe the definition of a setting event, i.e.
“The setting events are aspects of person’s environment or daily routines that increase the
probability of occurrence of problem behaviors”
o According to the template created by Peter Adzhyan and Teri Ede, the following setting events
should be recognized as accounted for within the FBA. Any setting events which may impact
behavior should be explored in this section:
 Medication, Medical, Physical Problems and Gender Specific conditions
 Sleep cycle and fatigue

NAME: DOB: REPORT DATE:

Confidential Functional Behavior Assessment Report page 4
  Eating routines and diet
 Physical environment & Social Events
 Changes in home environment including changes in residence
 Changes in school environment or staff (e.g. substitute, or new teacher or aide)
 Change in routine
 Noise level and number of people in the environment
 Exposure to heat, or bright lights and/or small spaces
 Predictability of daily schedules
 Social conflicts (with parents, siblings or peers)
 Level of academic and communication skills
 Reading, writing, math, communication, etc.

V. Summary of Interviews and Hypothesized predictor(s) (setting event(s) and immediate antecedent(s))
and potential function(s) of problem behavior(s) per parent and teacher input:
o Combine the information from sections I, II, III and IV and for each behavior include:
 Setting events that could increase the occurrence of the problem behavior
 Immediate antecedents that could evoke the problem behavior
 Possible function(s) that maintains or maintain the problem behavior(s)
 If desired, use the summary information in section V to complete the following table for
each of the behaviors listed in section I.

Setting Events Possible Antecedent Behavior Consequence Possible Function

Direct Assessment and Observation

I. Operational Definition of Target Behaviors

o Operationally define each target problem and appropriate behaviors
o Operational definition must be observable and measurable

II. Direct Observation Data

o You may wish to include this statement in the report: “To decrease negative impact to the
reliability and the validity of the obtained data, the days/times of observations and assessment
were either randomly selected, or targeting toward the times of the day that the behavior occurs
at highest frequency.
o Report the name of the observer, the date of each observations and the times of observations.
o Include any objective narrative data collection in this section.

III. Analysis of the Learning Environment for example:

o Presence of observable and measurable rules and daily schedules.
o Presence of posted daily schedule and how often the teacher follows the schedule as it is
written.
o Percent of students who are on task
o Average latency for starting academic work, following directions and/or transitions for at least 80
% of the class
o Student / staff ratio
o Physical Space

NAME: DOB: REPORT DATE:

Confidential Functional Behavior Assessment Report page 5
 o Describe class wide behavior support, if applicable. If there is a class-wide behavioral
intervention system, describe the existing procedure

IV. Baseline Frequency, Duration and Latency Data

o Include line graphs each identified target behavior, and a figure caption that describes each
graph.
o Frequency data:
 Report the average frequency for each targeted behavior. For behavior that has a
duration of 5 seconds or more (e.g. off task, tantrums, elopement) report duration.
o Duration data:
 Report the average duration only for target behavior that lasts more than 5 seconds.
 Duration can be reported in minutes or seconds
o Latency data:
 Measuring the amount of time that lapses between an antecedent (e.g., teacher's
directive) and when the student begins to perform a specified behavior.
 This type of data collection is appropriate for behaviors that follow a command or
directive, or a distinct stimulus.

V. Antecedent, Behavior, Consequence and Function

In order for an antecedent or consequence to be considered to have positive relationship with a specific
behavior, the behavior must occur more often in the presence of that specific antecedent or consequence
than in its absence. Antecedents must be observable.

Target Behavior 1: List first target behavior from initial graph.

Antecedent: Based on interview, observation and data collection.
Consequence: Based on interview, observation and data collection.
Hypothesized function(s): Based on ABC analysis, choose one or more of the following and provide a description of
rationale.
1. Escape/Avoidance:
2. Attention:
3. Access to Tangible Item:
4. Sensory Related:

Target Behavior 2: List first target behavior from initial graph.

Antecedent: Based on interview, observation and data collection.
Consequence: Based on interview, observation and data collection.
Hypothesized function(s): Based on ABC analysis, choose one or more of the following and provide a description of
rationale.
1. Escape/Avoidance:
2. Attention:
3. Access to Tangible Item:
4. Sensory Related:

Target Behavior 3: List first target behavior from initial graph.

Antecedent: Based on interview, observation and data collection.
Consequence: Based on interview, observation and data collection.
Hypothesized function(s): Based on ABC analysis, choose one or more of the following and provide a description of
rationale.
1. Escape/Avoidance:
2. Attention:
3. Access to Tangible Item:
4. Sensory Related:

NAME: DOB: REPORT DATE:

Confidential Functional Behavior Assessment Report page 6
 VI. Functionally Equivalent Replacement Behavior (FERB)
In order to decrease the frequency of the target behavior, it is necessary to identify alternative behaviors
that will serve the same purpose. In other words, what can the student do that is more appropriate but will
still allow him or her to obtain the desired result/function? In order to be effective, alternative behaviors
must be as easy for the student to perform as the target behavior one is attempting to extinguish. In
addition, the responses to the alternative behaviors must occur quickly and reliably. A description of
teaching strategies required for each FERB will be included within the recommendation section of this
report. Below are a list of proposed FERBs related to each target behavior:

Target Behavior 1: List first target behavior from initial graph.

Hypothesized function(s):
1. Escape/Avoidance:
2. Attention:
3. Access to Tangible Item:
4. Sensory Related:
Proposed Functionally Equivalent Replacement Behavior: What will the student do INSTEAD of the target
behavior to obtain that same desired result?

Target Behavior 2: List first target behavior from initial graph.

Hypothesized function(s):
1. Escape/Avoidance:
2. Attention:
3. Access to Tangible Item:
4. Sensory Related:
Proposed Functionally Equivalent Replacement Behavior: What will the student do INSTEAD of the target
behavior to obtain that same desired result?

Target Behavior 3: List first target behavior from initial graph.

Hypothesized function(s):
1. Escape/Avoidance:
2. Attention:
3. Access to Tangible Item:
4. Sensory Related:
Proposed Functionally Equivalent Replacement Behavior: What will the student do INSTEAD of the target
behavior to obtain that same desired result?

Reinforcement Survey

 Identify potential reinforcers for meaningful behavioral planning by asking the student, observing
preferences, or asking parents or other teachers.
 Potential reinforcement questions may include:
o Activity Reinforcers e.g., computer time, extra recess, drawing, reading, etc
o Tangible Reinforcers e.g., favorite items, toys, music, etc.
o Social Reinforcers e.g., visiting favorite adults, extra time with peers, etc.
o Academic Reinforcers e.g., display work, recognition or praise, stickers, etc.
o Edible Reinforcers e.g., drinks, snack, etc.
o How often does the student appear to need activity or tangible reinforcers in order to maintain
appropriate behaviors? Weekly? Daily? More than once per day? Specify.
o How often does the student receive positive attention from adults in school?

NAME: DOB: REPORT DATE:

Confidential Functional Behavior Assessment Report page 7
 Summary and Conclusions

 The summary should provide a brief description of relevant background information and the assessment
findings.
o Paragraph one:
 Name, reason for referral, age, grade, eligibility and current services
 Current academic performance
 Behavior that impacted educational performance
 Current behavioral interventions and their effectiveness
o Paragraph two:
 Setting events that could impact the target behaviors
 Frequency of target behaviors
 Duration/latency of target behaviors
o Paragraph three:
 Summary of ABC data including proposed functions of behavior(s)

Recommendations

After thorough consideration of the general education curriculum and the student’s specific strengths, weaknesses,
and needs, the following recommendations are deemed appropriate by the assessment team and should allow for
the student to access the general education curriculum, make adequate progress and receive educational benefit.
The following interventions are intended to be suggested strategies to facilitate learning and not to be interpreted
as accommodations mandated in an IEP. Final recommendations related to behavior planning and the development
of a behavioral goal and/or Behavior Intervention Plan (BIP) will be made by the IEP team.

o Each student will have a different set of needs due to their unique profile. Thus, recommendations should be
individualized.
o Recommendations should not include 1:1 aide, discussion of placement, service minutes, etc, which are
decisions of the IEP team.

I. Recommended antecedent interventions:

o For each setting event that increases the occurrence of the target behavior recommend an antecedent
intervention that would neutralize the effect of the setting event
o For each problem behavior recommend an antecedent intervention that will decrease the occurrence of
the target problem behaviors
o All antecedent interventions must include specific details that will help in development of the
intervention plans.
 Procedure for initial implementation
 Use of prompts (if needed)
 How to fade in and out the antecedent stimulus

II. Recommended consequence based interventions

o For each problem behavior recommend a consequence based intervention that uses the identified
function of each behavior to increase alternative appropriate behaviors to problem behaviors and/or
decrease the occurrence of problem behaviors to acceptable levels.
o Always recommend least intrusive interventions first (positive or negative reinforcement procedures
before punishment procedures)
 If recommending positive punishment strategies (time out or response cost) always combine with
positive reinforcement strategies

NAME: DOB: REPORT DATE:

Confidential Functional Behavior Assessment Report page 8
 o All consequence based interventions must include specific details that will help in development of the
intervention plans.
 The initial schedule of reinforcement (based on the baseline data)
 Specific items or actions to be used as possible reinforcers (from preference assessment)
 Use of prompts
 When to fade the frequency of reinforcement

III. Recommended Reactive Strategies

o Recommend a procedure that could be used when the problem behavior occurs
 Describe how the procedure could be implemented
 People involved
 Resources and locations

IV. Recommended Teaching Strategies

o List teaching strategies to decrease target behavior and increase successful use of the FERB(s)
o If multiple target behaviors/FERBs are to be addressed, list recommendations to align with each target
behavior and FERB individually

V. Data collection and analysis recommendations

o How often data should be collected
o Data collection forms (include sample in the Appendix if appropriate)
o Person responsible for data entry and analysis
o When to review the effectiveness of the plan
 Set a clear criterion for change in procedures or revision of the plan

VI. Communication recommendations

o How often consultation will occur between staff members/parents and what content will be
o How often consultation will occur between parents and staff
o How often will the parent be informed of progress?

______________________________________
____________________________________
Mr./Ms./Mrs. Psych Date
School Psychologist

NAME: DOB: REPORT DATE:

Confidential Functional Behavior Assessment Report page 9