Functional Behavior Assessment
Name: __________________________________ Date of Evaluation: ___________________
Address: ________________________________ Date of Birth: _______________________
I. History and Description:
A brief description of the person. Include strengths and abilities such as ambulation, communication
and self-care skills or independence level.
II. Risk Level:
Is this person’s behavior a risk to the community, peers or him/herself? What is the best staffing ratio
when at home, at work, in the community? What can impact the staffing level?
III. Health Information:
A. Current Diagnoses: List the mental and physical health diagnoses from the most recent
evaluation. Include the date of the evaluation the name of the provider
B. Current Medications: List the medications the person receives. No need to include dosages or
administration time.
C. Medical/Psychiatric Influences on Behavior: How do the medical and psychiatric diagnoses
affect this person’s behavior? Do not define the diagnoses, but state how the person is impacted
by the diagnosis. If the diagnosis doesn’t have an impact, state that.
IV. Previous Interventions and Effects:
What other behavior support programs have been tried, and what impact have they had? What has
worked? What has not worked?
V. Functional Assessment:
A. Target Behaviors and Definitions: Operationally define each target behavior in observable terms
so that someone can picture this behavior. It may be helpful to specify what is not included in
this definition (e.g. Self-Injurious Behavior (SIB) biting, scratching hands, arms and face. This
includes all attempts. This does not include biting finger nails.)
B. Baseline Measures of Target Behaviors: Include the monthly behavior data, for all target
behaviors, from the previous year in either a graph or table form.
C. Physical/Mechanical Restraint Use in Past Year: The number of physical or mechanical restraint
episodes during the past year. A summary of the common circumstances should be included.
D. Indirect Assessment: Interview of the staff who are most familiar with this person regarding the
circumstances surrounding target behaviors-antecedents and consequences for each target
behavior. May administer a structured interview such as Questions About Behavior Function
(QABF) to develop initial hypotheses regarding the reinforcement that maintains the behavior(s)
(the function of the behavior).
E. Direct Assessment /Observations Complete direct observations of the individual. Collect and
provide data regarding the antecedents (what happened before the behavior) and the
consequences (what happened after the behavior) each time the target behavior is observed.
What are the common antecedents and consequences for each target behavior? Those
antecedents and consequences indicate the function of each of the target behaviors. This also
