MARQUETTE-ALGER REGIONAL EDUCATIONAL SERVICE AGENCY

321 East Ohio Street

Marquette, Michigan 49855

Phone: (906) 226-5100

Functional Behavioral Assessment

Student Name:
Date of Birth:
CA:
School:
Teacher(s):
Grade:
Eligibility:
FBA Facilitator:
Date of Meeting:
Participants:

STATEMENT OF CONCERN: (General)

STUDENT STRENGTHS/INTERESTS/RESOURCES:

HISTORY:

BEHAVIORS OF CONCERN: (List)

PRIORITY TARGET BEHAVIORS TO BE ADDRESSED (no more than 2)

OPERATIONAL DEFINITION OF TARGET BEHAVIORS:

PAST INTERVENTION FOR IDENTIFIED TARGET BEHAVIORS:

PRECURSORS OF UNWANTED TARGET BEHAVIOR:

VARIABLES:

WHAT HAPPENS AFTER THE BEHAVIOR OCCURS:

SUSPECTED FUNCTION OF BEHAVIOR:

APPROPRIATE REPLACEMENT BEHAVIOR:

RECOMMENDATIONS:

Follow Up:
Next Meeting Date:
Location:
Person Responsible:
Phone:
Participants Necessary:

This assessment has been reviewed by the following:

Parent Signature:
Administrator Signature (or designee):

Document1

TEAM BEHAVIORAL PLANNING GUIDE FOR FUNCTIONAL BEHAVIORAL ASSESSMENT

Jodi Ball

2007-10-09

MAPS