Functional Assessment Checklist For Teachers And Staff Template Page 2
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2Functional Assessment Checklist for Teachers & Staff (FACTS-Part B)
Student/ Grade: ____________________________ Date: ______________________________________
Step 1
Interviewer: _______________________________ Respondent(s): ______________________________
Routine/Activities/Context: Which routine (only one) from the FACTS-Part A is assessed?
Step 2
Routine/Activities/Context
Problem Behavior(s)
Name
Provide more detail about the problem behavior(s):
Step 3
What does the problem behavior(s) look like?
How often does the problem behavior(s) occur?
How long does the problem behavior(s) last when it does occur?
What is the intensity/level of danger of the problem behavior(s)?
What are the events that predict when the problem behavior(s) will occur? (Predictors)
Step 4
Related Issues (setting events)
Environmental Features
___ illness
Other:_________________
___ reprimand/correction ___ structured activity
___ drug use
______________________
___ physical demands
___ unstructured time
___ negative social
______________________
___ socially isolated
___ tasks too boring
___ conflict at home ______________________
___ with peers
___ activity too long
___ academic failure ______________________
___ Other
___ tasks too difficult
____________________________ ____________
What consequences appear most likely to maintain the problem behavior(s)?
Step 5
Things that are Obtained
Things Avoided or Escaped From
___ adult attention
Other: ________________
___ hard tasks
Other: ___________________
___ peer attention
______________________
___ reprimands
________________________
___ preferred activity ______________________
___ peer negatives ________________________
___ money/things
______________________
___ physical effort ________________________
___ adult attention ________________________
SUMMARY OF BEHAVIOR
Identify the summary that will be used to build a plan of behavior support.
Setting Events & Predictors
Problem Behavior(s)
Maintaining Consequence(s)
Step 6
How confident are you that the Summary of Behavior is accurate?
Step 7
Not very confident
Very Confident
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Step 8
What current efforts have been used to control the problem behavior?
Strategies for preventing problem behavior
Strategies for responding to problem behavior
___schedule change
Other: ____None___
___ reprimand
Other: _____None_____
___ seating change
______________________
___ office referral _________________________
___ curriculum change ______________________
___ detention
_________________________
March, Horner, Lewis-Palmer, Brown, Crone, Todd, & Carr (2000)
4/24/00
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