Functional Behavioral Assessment Page 3
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6Functional Behavioral Assessment
Data Record Form
Student Name or ID: ___________________________________
DOB: _______________________
Date: _________________________
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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