Functional Behavioral Assessment

Be very specific when responding to the questions on this form. The comments will be used to generate a Positive Behavioral Intervention Plan for the student.
Name: 


A red asterisk (*) indicates required questions.

  1. Describe (in detail) the behavior(s) of concern.*


  1. How often does the behavior(s) occur?*
    more than 3 times per week
    2-3 times per week
    no more than 1 time per week
    1-2 times per week


  1. How long does the behavior(s) last?*


  1. How intense is the behavior? 1 being "not intensive" to 5 being "very intensive"*
    1 2 3 4 5


  1. What is happening when the behavior occurs?*


  1. When/where is the behavior most likely to occur?*


  1. With whom is the behavior most likely to occur? least likely?*


  1. What, in your opinion sets off the behavior?*


  1. How can you tell when the behavior is about to start?*


  1. What normally happens after the behavior has surfaced?*


  1. Why do you think the student behaves this way? What does the student get or avoid when the behavior occurs?*


  1. What other information do you have to offer to contribute to creating an effective behavioral intervention plan for the student?





Nicole Dandridge
Algebra I Part 1
Highland Springs High School
Highland Springs, VA