Functional Behavioral Assessment

Data Record Form

The Functional Behavioral Assessment (FBA) Data Record Form is a comprehensive data collection and synthesis
tool designed to assist the professionals in determining what function a specific behavior serves for a student. A
FBA is the foundation on which a behavioral intervention plan may be developed.
Behavioral Information
Description of target behavior:
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Setting(s) in which the behavior occurs:
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Frequency of behavior:
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Intensity of behavior:
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Duration of behavior:
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Functional Behavioral Assessment
Data Record Form

Student Name or ID:

__________________________DOB:____________Date:_______________

Behavioral Information (continued)
Antecedent(s):
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Concurrent event(s):
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Consequence(s) of behavior:
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Functional Behavioral Assessment
Data Record Form

Student Name or ID: ___________________________________

DOB: _______________________ Date: _________________________

Background Information
Observation(s): Check for each observation completed. Include date, time and setting. Multiple observations may
be completed if deemed of specific value. Attach a record of each observation to this document.
? Observation 1: Date/Time: _________________________Setting:______________________________________
? Observation 2: Date/Time: _________________________Setting : _____________________________________
? Observation 3: Date/Time: _________________________Setting: ______________________________________
? Observation 4: Date/Time: _________________________Setting: ______________________________________
? Observation 5: Date/Time: _________________________Setting: ______________________________________
Interviews: Check for each interview conducted. Attach a record or summary of each interview to this document.
? parent or guardian
? student
? school staff knowledgeable of student behavior_____________________________________________________
? school staff knowledgeable of student behavior _____________________________________________________
? school staff knowledgeable of student behavior _____________________________________________________
? other person(s) knowledgeable of student behavior __________________________________________________
Student records: Check for each student record reviewed. Include a brief summary. Attach additional summary
information as necessary.
?attendance
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?discipline
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?academic performance ______________________________________________________________________________________________
?prior assessment(s) ______________________________________________________________________________________________
?health record ______________________________________________________________________________________________
?other record
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