Functional Assessment Checklist For Teachers And Staff Template
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1
2Functional Assessment Checklist for Teachers and Staff (FACTS-Part A)
Step 1
Student/ Grade: ______________________________
Date: ____________________________
Interviewer: _________________________________
Respondent(s): ____________________
Step 2
Student Profile: Please identify at least three strengths or contributions the student brings to school.
______________________________________________________________________________________
Problem Behavior(s): Identify problem behaviors
Step 3
___ Tardy
___ Fight/physical Aggression
___ Disruptive
___ Theft
___ Unresponsive
___ Inappropriate Language
___ Insubordination
___ Vandalism
___ Withdrawn
___ Verbal Harassment
___ Work not done
___ Other ________________
___ Verbally Inappropriate
___ Self-injury
Describe problem behavior:
____________________________________________________________
Identifying Routines: Where, When and With Whom Problem Behaviors are Most Likely.
Step 4
Schedule
Activity
Likelihood of Problem Behavior
Specific Problem Behavior
(Times)
Before School
Low
High
1
2
3
4
5
6
Math
1
2
3
4
5
6
Transition
1
2
3
4
5
6
Language Arts
1
2
3
4
5
6
Recess
1
2
3
4
5
6
Reading
1
2
3
4
5
6
Lunch
1
2
3
4
5
6
Science
1
2
3
4
5
6
Transition
1
2
3
4
5
6
Block Studies
1
2
3
4
5
6
Art
1
2
3
4
5
6
Select 1-3 Routines for further assessment: Select routines based on (a) similarity of activities
(conditions) with ratings of 4, 5 or 6 and (b) similarity of problem behavior(s). Complete the FACTS-
Step 5
Part B for each routine identified.
March, Horner, Lewis-Palmer, Brown, Crone, Todd & Carr (2000)
4/24/00
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