Part I: Functional Behavior Assessment
| Summary of Student Profile Information |
| Name: Date of Birth: Grade: Exceptionality: Summary of 16 questions from Student Profile Information |
| Parent and Student Interviews |
| Provide a detailed summary of the parent and student interviews |
| Summary of Results of Social Skill Checklist and Motivation Assessment Scale |
| Target Behavior |
| State the behavior that you want to increase or decrease in one sentence |
| ABC Charts |
| Observation 1 |
| A-B-C Recording Form Date: _____________________Location: ____________________________________ Observer’s name _____________________________Length of time observed: ___________ Date / Time Antecedent Behavior Consequence |
| Observation 2 |
| A-B-C Recording Form Date: _____________________Location: ____________________________________ Observer’s name _____________________________Length of time observed: ___________ Date / Time Antecedent Behavior Consequence |
| Antecedent, Behavior, Consequence Summary Statement |
| 1. The antecedent is….. 2. The behavior is…… 3. The consequence…. |
| Function of the behavior |
| Based on the ABC charts provided and the results of the Behavior Rating Scale the function of the behavior is…… |
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