functionalassessmentchecklistforteachersandstaff-pbis.docVIP

Functional Assessment Checklist for Teachers and Staff (FACTS-Part A) Student/ Grade: ______________________________ Date: ____________________________ Interviewer: _________________________________ Respondent(s): ____________________ Student Profile: Please identify at least three strengths or contributions the student brings to school. ___________________________________________________________________________________ ___________________________________________________________________________________ Problem Behavior(s): Identify problem behaviors ___ 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Aggression ___ Disruptive ___ Theft ___ Unresponsive ___ Inappropriate Language ___ Insubordination ___ Vandalism ___ Withdrawn ___ Verbal Harassment ___ Work not done ___ Other ________________ ___ Verbally Inappropriate ___ Self-injury Describe problem behavior: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. Schedule (Times) Activity Likelihood of Problem Behavior Specific Problem Behavior Low High 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 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-Part B for each routine identified. March, Horner, Lewis-Palmer, Brown , Crone,