In a school or camp setting, where the management deals with a number of children or young adults, a functional behavior assessment form is a vital tool. It is used to gauge the conduct and note areas, in the participants, that may require correction. This form serves to determine the seriousness of the manners, if any, and to determine which participants are best mannered and which ones have the worst behaviors.
Functional Behavior Assessment form
Student Name: _____________________ Student ID: ____________ DOB: ____________
Case Manager: _____________________ Title: __________________________________
Sources of behavior data: Observation ___ Student Interview___ Teacher Interview ___
Rating Scales ___ Parent Interview____ Normative Testing___
Number: ________ Behavior Description: ______________________________________
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Setting(s) in which behavior occur _____________________________________________
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Frequency of occurrence _____________________________________________________
Occurrence Intensity (consequences on student, peers and environment) _______________
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Duration __________________________________________________________________
Previous Interventions _______________________________________________________
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Educational impact: _________________________________________________________
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Affective Regulation/Emotional Reactivity ________________________________________
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Cognitive Distortion _________________________________________________________
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Reinforcement _____________________________________________________________
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Antecedents: ________________________________________________________
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Consequences: _______________________________________________________
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Conclusion: _______________________________________________________________
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Case Manager Signature: ______________________ Date: _______________________
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