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Functional Behavior Assessment

Functional behavior Assessment Section I: Description Data Sources:! Observation! student interview! Parent Interview Description of the behavior Setting(s) in which the behavior occurs Frequency of behavior Duration of behavior Consequences to peers, staff members, or instructional environment Teaching Children with Autism version 1.

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ChangBroot
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779 views

Functional Behavior Assessment

Functional behavior Assessment Section I: Description Data Sources:! Observation! student interview! Parent Interview Description of the behavior Setting(s) in which the behavior occurs Frequency of behavior Duration of behavior Consequences to peers, staff members, or instructional environment Teaching Children with Autism version 1.

Uploaded by

ChangBroot
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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Functional Behavior Assessment Date:

Section I: Description Child:


Data Sources: ! Observation | ! Student Interview | ! Parent Interview Assessed by:

Description of the behavior

Setting(s) in which the behavior occurs

Frequency of behavior

Duration of behavior

Consequences to peers, staff members, or instructional environment

Descriptions of or references to previous interventions

polyxodotcom
Copyright 2001, Jason M. Wallin Version 1.0
Oak Harbor, Washington
Teaching Children with Autism
http://www.polyxo.com/

The latest version of this document is available at http://www.polyxo.com/documents/


Functional Behavior Assessment Date:
Section II: Analysis of Function Child:
Check the hypothesized function(s) for the behavior and describe Assessed by:

! Gain attention

! Gain a tangible consequence

! Gain a sensory consequence

! Escape from or avoidance of an undesirable situation

! Affective regulation / emotional reactivity

! Make a comment or declaration

! Release tension

! Fill a habitual need

! Other

polyxodotcom
Copyright 2001, Jason M. Wallin Version 1.0
Oak Harbor, Washington
Teaching Children with Autism
http://www.polyxo.com/

The latest version of this document is available at http://www.polyxo.com/documents/


Functional Behavior Assessment Date:
Section III: Behavioral Intervention Plan Child:
Assessed by:

Expected Outcomes / Interventions &


Intervention Review Notes
Replacement Behaviors Frequency of Interventions
Person Responsible

Review Dates

1 ______________

1
2 ______________

3 ______________

4 ______________

Person Responsible

Review Dates

1 ______________

2
2 ______________

3 ______________

4 ______________

Person Responsible

Review Dates

1 ______________

3
2 ______________

3 ______________

4 ______________

Person Responsible

Review Dates

1 ______________

4
2 ______________

3 ______________

4 ______________

polyxodotcom
Copyright 2001, Jason M. Wallin Version 1.0
Oak Harbor, Washington
Teaching Children with Autism
http://www.polyxo.com/

The latest version of this document is available at http://www.polyxo.com/documents/

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