functional assessment interview and observation
TRANSCRIPT
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FUNCTIONAL ASSESSMENT INTERVIEW
(adapted from O’Neill, R., Horner, R., Albin, R., Sprague, J. R., Storey, K., and Newton, J. S. 1!."#un$tional A%%e%%ment &nter'iew. &n #un$tional A%%e%%ment and )rogram *e'elopment+ A )ra$ti$al
Handboo, -nd dition. )a$ifi$ /ro'e+ 0roo%2ole )ubli%3ing 2ompany4
Student Name 23ild 0 Age ! Se5 6ale
*ate of &nter'iew -nd No'ember -718 &nter'iewer 9ea$3er
Re%pondent% 9ea$3er
I. Student Behavior
A. List the strengths and o!"etenies o# the student in eah o# the do!ains$
So$ial+
• Able to re%pond to familiar %o$ial a$tion% (eg. Hi:;, %3ae 3and%, a$$epting item%4
• Able to %tay in a %mall group wit3 3i% peer% during group wor %e%%ion%
• Able to demon%trate le'el of awarene%% by taing toy% from 3i% peer% w3en t3ey tae t3em
away from 3im
A$ademi$ 2ogniti'e+
• 6at$3ing ob
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2ommuni$ation+
• 2urrently on )i$ture 5$3ange 2ommuni$ation Sy%tem ()2S4
• Able to $omplete )3a%e & of )2S = %imple 1 to 1 e5$3ange wit3 different reinfor$er%
• 2urrently woring on )3a%e && and &&& of )2S = waling a$ro%% t3e room to $omplete t3e
e5$3ange and di%$riminating between two different )2S $ard%
a% &esri'e the 'ehaviors o# onern$
1.Behaviour &esri"tion Fre(uen) &uration Intensit)
1. #looring 23ild will drop to t3e
ground (%ometime% roll
on t3e floor4 and begin
to purpo%ely mae 3im
feel 3ea'y %o t3at
ot3er% are not able to
$arry 3im.
>3ene'er 3e doe% not
want to do %omet3ing
t3at t3e tea$3er dire$t%
3im to.
?min% = 17 min%
(depending on w3at
t3e tea$3er re@uire%
3im to do4
Hig3 = 23ild
%truggle w3en tea
trie% to $arry 3im
%tand up.
-. 0iting S3irt 23ild will bite 3i% %3irt$on%tantly and t3at
would $au%e many
3ole% on 3i% %3irt%.
>3ene'er 3e get%up%et, angry or o'erly
e5$ited.
O'er ?7 min% w3entea$3er doe% not
prompt 3im to %top
biting 3i% %3irt.
; %e$ond% w3en
tea$3er prompt% 3imto %top biting 3i% %3irt.
ow = 23ild doe%%3ow fru%tration w
3e i% prompted to
biting 3i% %3irt. A
3e doe% not tri
ot3er $3ildren in$la%% wit3
be3a'iour.
?. Ki$ing and
2rying
23ild will lie down on
t3e floorB u%e 3i% 3and%
to $o'er 3i% ear% and
$ry, i$ing w3ate'er
tea$3er, peer or toy%around 3im.
>3ene'er 3e i% put in
a %etting t3at 3e i% not
$omfortable wit3.
O'er 1; min% for
e'ery meltdown.
Hig3 = 23ild
%3out and $au%e%
noi%e% t3at w
di%rupt t3e o
$3ildren in t3e $Some $3ildren wi
triggered and
meltdown% a% due to t3e loud no
8. 93rowing t3ing% 23ild will t3row t3ing%wit3 a lot of for$e
(toy%, food4 onto t3e
floor.
>3ene'er 3e i% %i$ of t3e food or gi'en
toy% t3at 3e doe% not
want.
- %e$ond% for t3rowing, at mo%t 1
min of t3rowing all
t3e t3ing% on t3e
table.
Hig3 = t3rowt3ing% may 3it o
$3ildren and
$au%e a lot of tea$
to $lean up after 3
-. >3i$3 of t3e be3a'ior% de%$ribed abo'e are liely to o$$ur toget3er in %ome wayC
93rowing t3ing% and biting %3irt
#looring, i$ing and $rying
?. >3at do you now about t3e 3i%tory of t3e unde%irable be3a'ior%, t3e program% t3at 3a'e been attempted
de$rea%e or eliminate t3em, and t3e effe$t% of t3o%e program%C
Behaviour *o+ ,ong has this 'een a
"ro',e!-
rogra!s E##ets
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1. #looring 23ild 3a% alway% been
flooring but 3a% %tarted
be$oming be3a'iour %in$e !
mont3% ago.
23ild will be gi'en %na$%
(eg. oreo4 to pa$ify 3im and
moti'ate 3im to wal.
)rogram 3a% been effe$ti'e to a
$ertain e5tend a% $3ild will get up
from t3e floor mo%t of t3e time.
-. 0iting S3irt 23ild 3a% been biting 3i%
%3irt %in$e 3e wa% ; year%
old.
23ild will be gi'en fruit%
%u$3 a% orange% (for t3e
%our ta%te4 and apple% (for
t3e $run$34 for 3i% %en%ory
diet.
)rogram 3a% been effe$ti'e in
beginning w3en 3e 3ad
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?. *e%$ribe %leep pattern% and po%%ible relation%3ip to be3a'ior+
23ild %leep% regular 3our% and doe% not 3a'e any po%%ible relation to 3i% be3a'iour
8. *e%$ribe eating routine% and diet and po%%ible relation%3ip to be3a'ior+
23ild eat% ba%i$ t3ree meal% a day but al%o %na$% alot t3roug3out t3e day. #ood i% u%ed a% a
%trategy to pa$ify 3im w3en 3e mi%be3a'e%.
;. Student’% daily %$3edule (&ndi$ate w3et3er t3ey are a$ti'itie% 3e%3e en
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:00
!:00
#urt3er detail%+ Inable to fill up t3e %$3edule for $3ild 0 before 3e attend% $la%% due to t3e parent% di%$retion
. How many other 'ersons are typi$ally around t3e %tudentC *oe% t3e %tudent typi$ally %eem bot3ered in
%ituation% t3at are more $rowded and noi%yC
S$3ool Home
9ea$3er Helper
9ea$3er Aide )arent%
9ea$3er Aide Sibling%
23ild %eem% to be more bot3ered in $rowded and noi%y %ituation% lie in %$3ool w3en t3ere are more %tudent%
around 3im.
!. >3at i% t3e pattern of %taffing %upport t3e %tudent re$ei'e%C *o you belie'e t3at t3e n(mber of %taff, t3etraining of %taff, or t3eir social interactions with the st(dent affe$t t3e de%irable or target be3a'iorC
S$3ool Home9ea$3er Helper : 3a% been wit3 $3ild e'er %in$e 3e
wa% born
9ea$3er Aide : trained in 3andling $3ildren
wit3 %e'ere AS*, proa$ti'e in $la%%room
%etting%
)arent%
9ea$3er Aide : trained in 3andling $3ildren
wit3 %e'ere AS*, proa$ti'e in $la%% %etting%
and trained in toileting
Sibling%
)attern or %taff and training of %taff are %uffi$ient for t3e $la%% $3ild 0 i% in. Student% are all diagno%ed wit3 AS
%imilar to $3ild 0.
. >3at agen$ie% are in'ol'ed wit3 t3e %tudentC
5f there is any social agency in&ol&ement 'lease see %gency 5n&ol&ement (estionnaire 3 %ttachment ".
C. &e#ine s"ei#i i!!ediate anteedent events that "redit +hen the 'ehaviors are likely and not
likely to our.
1. 9ime% of *ay+ When are t3e be3a'ior% mo%t and lea%t liely to 3appenC
4esirable 2arget ,ost i-ely >3en $3ild i% a%ed to mo'e from one
%etting to anot3er
>3en $3ild doe% not get w3at 3e want%
>3en $3ild i% a%ed to parti$ipate in
anyt3ing t3at i% tea$3er dire$ted
east i-ely >3en $3ild i% able to %ele$t 3i% $3oi$e of
a$ti'ity
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-. Setting%+ Where are t3e be3a'ior% mo%t and lea%t liely to 3appenC
4esirable 2arget ,ost i-ely *uring $ir$le time %etting
*uring group a$ti'ity %etting
east i-ely
?. )eople+ With whom are t3e be3a'ior% mo%t and lea%t liely to 3appenC
4esirable 2arget
,ost i-ely
east i-ely
8. A$ti'ity+ What acti&ities are mo%t and lea%t liely to produ$e t3e be3a'iorC
4esirable 2arget ,ost i-ely
east i-ely
;. Are t3ere parti$ular or idio%yn$rati$ %ituation% or e'ent% not li%ted abo'e t3at %ometime% %eem to
"%et off t3e be3a'ior%, %u$3 a% parti$ular demand%, noi%e%, lig3t%, $lot3ingC
. >3at one thing $ould you do t3at would mo%t liely mae t3e be3a'ior% o$$urC
4esirable 2arget
!. 0riefly de%$ribe 3ow t3e target be3a'ior would be affe$ted if. . .
a4 ou a%ed 3im or 3er to perform a diffi$ult ta%+
23ild 0 will floor and %truggle w3en being p3y%i$ally broug3t to perform a ta%.
b4 ou interrupted an en
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23ild will floor and %truggle, not wanting to mo'e from one area to anot3er if t3e routine i%
di%rupted. Inle%% it i% to bring 3im to an a$ti'ity t3at 3e prefer% (eg. water play4, $3ild will
parti$iapte and will not %3ow be3a'iour
d4 93e %tudent wanted %omet3ing but wa% unable to get it+
23ild will pu%3 tea$3er% out of t3e way in order to get %omet3ing t3at 3e prefer%
e4 ou didn’t pay attention to t3e %tudent or left t3e %tudent alone for aw3ile (e.g., 1; minute%4.
&f $3ild i% engaged in 3i% preferred a$ti'ity (eg. playing wit3 3i% preferred toy%4, $3ild will not
%3ow any be3a'iour. Howe'er, after aw3ile, 3e will %tart to run around t3e $la%%room and
t3row t3ing% on t3e floor.
&. Identi#) the onse(uenes or outo!es o# the "ro',e! 'ehaviors that !a) 'e !aintaining the!
/i.e.0 the #untions the) serve #or the student in "artiu,ar situations%. 93in of t3e be3a'ior% li%ted in Se$tion 0,
and identify t3e %pe$ifi$ $on%e@uen$e% or out$ome% t3e per%on get% w3en t3e be3a'ior% o$$ur in different %ituation%.
0e3a'ior )arti$ular Situation% >3at e5a$tly doe% t3e
%tudent getC
>3at doe% t3e %tudent a'
a4
b4
$4
d4
e4
E. Consider the overa,, efficiency o# the "ro',e! 'ehaviors. E##iien) i# the o!'ined resu,t o# /A% ho+
!uh "h)sia, e##ort is re(uired0 /B% ho+ o#ten the 'ehavior is "er#or!ed 'e#ore it is re+arded0 and /C%
ho+ ,ong the student !ust +ait to get the re+ard.
0e3a'ior
ow
ffi$ien$y
Hig3
ffi$ien$y
1 - ? 8 ;
1 - ? 8 ;
1 - ? 8 ;
1 - ? 8 ;
1 - ? 8 ;
F. What functional alternative 'ehaviors does the student a,read) 1no+ ho+ to do- />3at %o$ially appropri
be3a'ior% or %ill% $an t3e per%on already perform t3at may generate t3e %ame out$ome% or reinfor$e% produ$e
t3e problem be3a'ior%C4 2See Setion A #or strengths and o!"etenies.
3. What are the "ri!ar) +a)s the student o!!uniates +ith other "eo",e-
1. >3at are t3e general e5pre%%i'e $ommuni$ation %trategie% u%ed by or a'ailable to t3e %tudentC 93e%e mig3t
in$lude 'o$al %pee$3, %ign%ge%ture%, $ommuni$ation board%boo%, or ele$troni$ de'i$e%.
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-. How $on%i%tently are t3e %trategie% u%edC
?. On t3e following $3art, indi$ate t3e be3a'ior% t3e per%on u%e% to a$3ie'e t3e $ommuni$ati'e out$ome% li%te
Communication
Functions
C o ! " , e 4 s " e e h
/ s e n t e n e s % M
u , t i " , e 2 + o r d " h r a s e s
O n e 2 + o r d u t t e r a n e s
E h o , a , i a
O t h e r v o a , i 5 i n g
C o ! " , e 4 s i g n i n g
S i n g , e s i g n s
. o i n t i n g
L e a d i n g
S h a 1 e s h e a d
3 r a ' s 6 r e a h
e s
3 i v e s o ' 7 e
t s
I n r e a s e d ! o v e ! e n t
M o v e s , o s e t o ) o u
M o v e s a + a ) o r , e a v e s
F i 4 e d g a 5 e
F a i a , e 4 " r e s s i o
n
A g g r e s s i o n
S e , # 2 i n 7 u r )
O t h e r
Re(uest attention
Re(uest he,"
Re(uest "re#erred
#ood2o'7ets ativities
Re(uest 'rea1
Sho+ )ou so!ething
or so!e ",ae
Indiate "h)sia, "ain
/headahe0 i,,ness%
Indiate on#usion
or unha""iness
rotest or re7et a
situation or ativit)
8. >it3 regard to t3e %tudent’% re$epti'e $ommuni$ation, or ability to under%tand ot3er per%on%. (#or ea$3
item, li%t if only a few4.
a4 *oe% t3e %tudent follow %poen re@ue%t or in%tru$tion%C &f %o, appro5imately 3ow manyC
b4 *oe% t3e %tudent re%pond to %igned or ge%tural re@ue%t% or in%tru$tion%C &f %o, appro5imately 3ow manyC
$4 &% t3e %tudent able to imitate if you pro'ide p3y%i$al model% for 'ariou% ta%% or a$ti'itie%C
d4
How doe% t3e %tudent typi$ally indi$ate yes or no w3en a%ed if 3e or %3e want% %omet3ing, want% to go
%omew3ere, and %o onC
I. What are the things )ou shou,d do and things )ou shou,d avoid in +or1ing +ith and su""orting this
"erson-
1. >3at t3ing% $an you do to impro'e t3e lieli3ood t3at a tea$3ing %e%%ion or ot3er a$ti'ity will go well
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wit3 t3i% %tudentC
-. >3at t3ing% %3ould you a'oid t3at mig3t interfere wit3 or di%rupt a tea$3ing %e%%ion or a$ti'ity wit3
t3i% %tudentC
8. What are things the student ,i1es and are rein#oring #or hi! or her-
1. A$ti'itie% in %$3ool+
-. A$ti'itie% at 3ome+
?. A$ti'itie% in $ommunity+
8. Ob
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Attah!ent 9
:uestions to as1 i# a student is in #oster are$
1. >3o 3a% $u%tody of t3e $3ildC &% t3i% a parentfo%ter parent relati'e friendC 2omment%Note%
a.
b.
-. &f t3e $3ild i% in publi$ $u%tody, w3o i% t3e $3ild’% $a%e worerC
a. 93e $a%e worer a$t% a% $u%todian.
b. 93ere i% a %pe$ifi$ group of $3ildren w3o are being %er'ed by a 23ildren’%
Home. 93e%e $3ildren are all eligible for adoption, and awaiting familie%. &n
t3e%e $a%e%, t3e %taff per%on from 23ildren’% Home a$t% a% t3e $u%todian.
?. &n w3at type of fo%ter 3ome i% t3e $3ild pla$edC
8. >3o i% t3e $3ild’% /uardian Ad item 2ourt Appointed Spe$ial Ad'o$ateC
a. 93e /uardian Ad item (/A4 i% a per%on appointed by a magi%trate in
3at %er'i$e% i% t3e $3ild re$ei'ingC
a.
b.
. *oe% t3e $3ild 3a'e an a$ti'e $a%e wit3 a mental 3ealt3 agen$y or pro'iderC
a. A $3ild in'ol'ed wit3 mental 3ealt3 %er'i$e% will 3a'e an 5ndi&id(ali8ed
1er&ice Plan) 51P/ t3at delineate% t3e goal% t3e $3ild i% woring on in t3erapy.
&S)% and &)% %3ould be $oordinated. b. Some t3erapi%t% $an be a'ailable to attend %$3ool meeting%.
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Attah!ent ;
Funtiona, Assess!ent O'servation For!
Name+
Starting *ate+ nding *ate+
)er$ei'ed #un$tion% A$tual
2on%[email protected]'ior% )redi$tor% %$apeA'oid /etObtain Sen%ory
9ime
# l o o r i n g
0 i t i n g S 3 i r t
K i $ , i n g
a n d 2 r y i n g
9 3 r o
w i n g t 3 i n g %
* e m a n d 1 R e @ u e % t
*
i f f i $ u l t 9 a % ,
9 r a n % i t i o n %
& n t e r r u p t i o n
A l o n e ( n
o a t t e n t i o n 4
* o e % n o t w a
n t t o b e i n a
9 $ 3 r . * e m a n d 1 R e @ u e % t
A $ t i ' i t y L 9
a % , ( / r o u p 4
) e r
% o n :
O t 3 e r :
9 e a $ 3
e r A t t e n t i o n
) e
e r A t t e n t i o n
# o o d
A $ $ e % % a t a % , :
A $ $ e % %
t o + d e % i r e d
i ' i t y
O t 3 e r 1
*
o n ’ % K n o w
/ r a t i f i $ a t i o n
5 $ i t e m e n t
(if not3ing
3appened in
period, write
initial%4
2omment%
?pm1
!
1
!1
1
!
1
!!
1
!! 1
?.?7pm 8 8 8 8 8 8
8pm - -
-
;
-
;
-
;
;
-
;
-
-
;
-
;
8.?7pm
;pm
?
?
?
?
?
?
?
?
;.?7pm
pm
9otal%
'ent%+ 1 - ? 8 ; ! 17 11 1- 1? 18 1; 1 1! 1 1 -7 -1 -- -? -8 -;
*ate+
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Student < &ireted Funtiona, Assess!ent Intervie+
Student Name+ &nter'iewer+
Referring 9ea$3er+ *ate+
I. O"ening. 9We are meeting today to find ways to change school so that yo( li-e it more. 2his inter&iew will ta-e abo(t $0 min(tes. 5 can hel' yo( best if yo( answer
honestly. o( will not be as-ed anything that might get yo( in tro(ble.;
Positi&e
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Mou will u%e t3e number% to t3e left a% $ode% for t3e identified be3a'ior% a% you $omplete t3e re%t of t3e inter'iew.
Su!!ar) State!ent For!
A$ti'ity or 'ent >3at Happen% 0efore 0e3a'ior(%4 >3at Happen% After
; 9 >
2omplete t3e diagram following t3e numbered %e@uen$e (0e3a'ior(%4 fir%t, t3en )redi$tor%, et$.4. 2on%ider t3e item% below a% po%%ible element% for in$lu%ion in t3e
diagram. 2omplete a different diagram for ea$3 new $on%e@uen$e.
>3at important e'ent% or a$ti'itie%
tend to %et up t3e be3a'iorC >3at appear% to %et off problem be3a'iorC >3at do t3e problem be3a'ior% loo lieC
>3at do you gain from t3e
problem be3a'ior%Ca$ of %leep 2la%% demand% t3at are+ ate to $la%% %$ape or A'oid
&llne%% 9oo 3ard 9al out in $la%% 9ea$3er demand%
)3y%i$al pain 0oring *i%ruption% 9ea$3er reprimand% $orre$tion
Hunger In$lear &nappropriate language )eer %o$ial $onta$t (tea%ing4
9rouble at 3ome ong *i%re%pe$ti'e be3a'ior 9a%% (3ard, long4
#ig3t$onfli$t wit3 peer% 9ea$3er reprimand% )roperty de%tru$tion /et Attention
Noi%edi%tra$tion% )eer tea%ing 2arrying weapon% #rom peer%
A$ti'ity$la%% )eer en$ouragement #idget #rom tea$3eradult
(%eating arrangement%4 Ot3er Not $ompleting wor /et A$ti'ity or &tem
(tea$3er error $orre$tion4 Steal A$$e%% to game93reaten A$$e%% to toy
Fandali%m A$$e%% to food
Ot3er A$$e%% to money
(looing around and waling4 A$$e%% to ta%
Sen%ory
)3y%i$al gratifi$ation
5$itementarou%al
Student < &ireted Funtiona, Assess!ent Intervie+0 ".>
Student &ai,) Shedu,e
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)lea%e pla$e an "E in ea$3 $olumn to %3ow t3e time% and $la%%e% w3ere you 3a'e diffi$ulty wit3 t3e be3a'ior% we taled about. &f you 3a'e a lot of diffi$ulty during a
period, pla$e an "E on or near t3e . &f you 3a'e a little diffi$ulty during t3e $la%% or 3all time, pla$e t3e "E on or near t3e 1. >e $an pra$ti$e on a $ouple toget3er
before we %tart.
Be#ore
Shoo,
9st
eriod
*a,, ;nd
eriod
*a,, >rd
eriod
*a,, ?th
eriod
Lunh @th
eriod
*a,, th
eriod
*a,, th
eriod
*a,, th
eriod
A#ter
Shoo,
Su'7et0
Teaher None None None None None None None None None
Most
&i##iu,t
@
?
>
;
Least
&i##iu,t
9
Ta',e 9
*)"othesis Su!!ar) State!ent Wor1sheet
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Setting andor Hi%tory 'ent or A$ti'ity
)redi$tor or 9rigger (Ante$edent4
9arget 0e3a'ior
6aintaining 2on%e@uen$e(/oal of t3e 0e3a'ior4
Setting andor Hi%tory 'ent or A$ti'ity
)redi$tor or 9rigger (Ante$edent4
9arget 0e3a'ior
6aintaining 2on%e@uen$e(/oal of t3e 0e3a'ior4
Setting andor Hi%tory 'ent or A$ti'ity
)redi$tor or 9rigger (Ante$edent4
9arget 0e3a'ior
6aintaining 2on%e@uen$e(/oal of t3e 0e3a'ior4
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Ta',e ;
Su!!ar) State!ent o# Re",ae!ent Behavior Strategies Wor1sheet
Setting andor Hi%tory
'ent or A$ti'ity
)redi$tor or 9rigger
(Ante$edent4
Repla$ement 0e3a'ior
(tae% t3e pla$e of t3eunde%ired be3a'ior4
*e%ired 0e3a'ior Re%ult
6aintaining $on%e@uen$e
Setting andor Hi%tory'ent or A$ti'ity
)redi$tor or 9rigger (Ante$edent4
Repla$ement 0e3a'ior (tae% t3e pla$e of t3eunde%ired be3a'ior4
*e%ired 0e3a'ior Re%ult
6aintaining $on%e@uen$e
Setting andor Hi%tory'ent or A$ti'ity
)redi$tor or 9rigger (Ante$edent4
Repla$ement 0e3a'ior (tae% t3e pla$e of t3eunde%ired be3a'ior4
*e%ired 0e3a'ior Re%ult
6aintaining $on%e@uen$e
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List Strategies that Ma1e the ro',e! Behavior Irre,evant0 Ine##etive0 D Ine##iient
Setting Event
Strategies
reditor
Strategies
Teahing
Strategies
Conse(uene
Strategies
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Bui,ding a Su""ort ,an
*e%ired 0e3a'ior 2on%e@uen$e%
Setting 'ent% )redi$tor% )roblem 0e3a'ior
Repla$ement 0e3a'ior 6aintaining 2on%e@uen$e%
)re'ention )re'ention &nter'ention>3at are way% to $3ange t3e
$onte5t to mae t3e problem
be3a'ior unne$e%%aryC
>3at are way% to pre'ent t3e problem
be3a'iorC
>3at $an be done to in$rea%e
e5pe$ted be3a'ior% or to tea$3 a
repla$ement be3a'iorC
>3at %3ould 3appen w3en
de%ired or repla$ement
be3a'ior o$$ur%C
>3at %3ould 3appen w3en a problem be3a'ior
o$$ur%C (>3at %trategie% from t3e pre'iou%
page would you u%e w3en t3e be3a'ior o$$ur%2larify rule% and e5pe$ted Reminder% about be3a'ior )ra$ti$e e5pe$ted be3a'ior in $la%% Reward programC
be3a'ior for w3ole $la%% w3en problem be3a'ior i% liely Self:management program )rai%e from tea$3er
>ritten $ontra$t wit3 t3e Student% )ro'ide e5tra a%%i%tan$e Ot3er gi&e 'rom'ts for eA'ected beha&ior/ Ot3er
Student %elf:manipulator %3eet 6odify a%%ignment% to mat$3 %tudent %il l%
23ange %eating arrangement%
23ange %$3edule
2oun%eling
Ot3er e.g.B more slee' at home/ Ot3er e.g.B shorter assignments) more time/
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Behavior Su""ort ,an
Student Name+
*O0+
*ate of )lan+
9ea$3er(%4+
)arti$ipant(%4+
9. Target Behavior/s% /state the "ro',e! 'ehavior in o'serva',e and !easura',e ter!s%$
;. Media, *istor)6Mediation6Menta, *ea,th &iagnosis$
>. *)"othesis/es% /re#er to Ta',e 9%$
?. Current Leve, o# Funtioning /state the #re(uen)0 intensit)0 and duration o# the 'ehavior 'ased
@. 3oa,s D O'7etives /in,ude state!ent o# Re",ae!ent Behaviors and &esired Behavior Resu,ts%$
. &ata Co,,etion Method$
. revention Ativities /re#er to Bui,ding a Su""ort ,an%$
. Intervention Ativities /re#er to Bui,ding a Su""ort ,an%$
. Crisis Manage!ent roedures$
9. Res"onsi'i,ities$93e following %taff will be managing t3e o'erall implementation of t3e plan+
>3o notifie% ot3er %taff of t3eir re%pon%ibilitie%C
i%t pre'ention and inter'ention %tep% and t3o%e indi'idual% re%pon%ible for ea$3+
)re'ention Step Re%pon%ible )er%on &nter'ention Step Re%pon%ible )er%on
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99. Re(uired !ateria,s0 training0 and sta## to i!",e!ent ",an$
a. 6aterial%+
b. 9raining+
$. Staff+
9;. Fo,,o+2u" ,ans$
>3o will meet again and w3en+
our %ignature indi$ate% you are aware of and are in agreement wit3 t3e implementation of t3i% plan.
)arent /uardianSurrogate 9ea$3er
Student 9ea$3er
S$3ool )%y$3ologi%t )rin$ipal
Agen$y Repre%entati'e Agen$y Repre%entati'e
Ot3er :9itle Ot3er :9itle