Functional Behavioral Assessment (FBA) Behavior of Concern Questionnaire Date: Student: School: Birth date: ID number: Grade: IEP: Yes No Student behavior Briefly describe the behavior of concern: Directions Keeping in mind a typical episode of the behavior of concern, circle the frequency at which each of the following statements are true. Never 10% 25% 50% 75% 90% Always 0 1 2 3 4 5 6 Does the behavior of concern occur and persist when you make a request to 0 1 2 3 4 5 6 perform a task? When the behavior of concern occurs, do you redirect the student to get on 0 1 2 3 4 5 6 task or follow rules? During a conflict with peers, if the student engages in the behavior of 0 1 2 3 4 5 6 concern, do peers leave the student alone? When the behavior of concern occurs, do peers verbally respond or laugh at 0 1 2 3 4 5 6 the student? Is the behavior of concern more likely to occur following a conflict outside of the 0 1 2 3 4 5 6 classroom (e.g., bus write up)? Does the behavior of concern to get your attention when you are working 0 1 2 3 4 5 6 with other students? Does the behavior of concern occur in 0 1 2 3 4 5 6 the presence of specific peers?
Functional Behavioral Assessment (FBA) Behavior of Concern Questionnaire Date: Student: School: Birth date: ID number: Grade: IEP: Yes No Student behavior Briefly describe the behavior of concern: Directions Keeping in mind a typical episode of the behavior of concern, circle the frequency at which each of the following statements are true. Never 10% 25% 50% 75% 90% Always 0 1 2 3 4 5 6 Does the behavior of concern occur and persist when you make a request to perform a task? 0 1 2 3 4 5 6 When the behavior of concern occurs, do you redirect the student to get on task or follow rules? 0 1 2 3 4 5 6 During a conflict with peers, if the student engages in the behavior of concern, do peers leave the student alone? 0 1 2 3 4 5 6 When the behavior of concern occurs, do peers verbally respond or laugh at the student? 0 1 2 3 4 5 6 Is the behavior of concern more likely to occur following a conflict outside of the classroom (e.g., bus write up)? 0 1 2 3 4 5 6 Does the behavior of concern to get your attention when you are working with other students? 0 1 2 3 4 5 6 Does the behavior of concern occur in the presence of specific peers? 0 1 2 3 4 5 6