FBA Report Checklist
Use of this report checklist as a guide throughout the entire FBA process. After the assessment
has concluded ALL boxes below must be checked in order for the FBA assessment to be
complete.hout the entire FBA process. After the assessment has concluded ALL boxes below
must be checked off in order to have a complete FBA report.
d off in order to have a complete FBA report.
I. Identifying Information
Name Special Education Eligibility
Date of Birth Current Placement
LAUSD Student ID # Previous Placement (N/A if not applicable)
Age Language Classification
Grade ELD Level
Gender Designated Instructional Services (DIS)
Home School Name of Assessor(s)
School of Attendance Date of Report
II. Reason for Referral
Origin of referral
Target problem behavior (definition of target problem behavior must be specific, observable, and
measureable).
Impact on child’s school performance
Information about how long the behavior has been occurring (e.g. since the beginning of the school
year, after winter break, etc.)
III. Interviews
Relevant discussion and summary of interviews:
Completed FACTS- staff and/or teacher
Completed Family-Directed Interview
Summary statement of antecedent, behavior, consequence, and possible function
IV. Observations
Ecological analysis:
Summary of Learning Environment Checklist (LEC)
Description of tiered supports in place
Class-wide motivation systems
Frequency and/or Duration Data:
Rate of the target problem behavior after three separate days of frequency data collection only
during the specified prioritized routine, and an average amount of time the target problem behavior
lasts during the specified prioritized routine. (*Duration data only needs to be reported if the
target problem behavior lasts more than three full minutes*)
ABC Observation:
At least 10 occurrences of the target problem behavior have been recorded OR at least three 30-
minute ABC data collection sessions have taken place
Each observation period took place for 30 consecutive minutes
Observations took place in locations and at times based on the routine analysis from FACTS
Brief summary of common antecedents and consequences observed
V. Summary Statement
Statement of the hypothesized function based on ABC observation data (from ABC Observation
Summary)
VI. Behavior Intervention Recommendations
Ecological/Antecedent Strategies
Information on students’ ability to communicate, pertinent skill deficits that may need
accommodations
Information on environment (i.e. access to objects and activities that can compete with problem
behaviors), structure of the classroom, routines in the classroom, and visual schedules
All ecological/antecedent strategies match the function of the target problem behavior
Teaching Strategies
Brief discussion of replacement behaviors, successive approximations, and desired behaviors
Information on how the student will learn replacement and desired behavior(s)
Information on when the student will demonstrate replacement and desired behavior(s)
All teaching strategies match the function of the target problem behavior
Consequence-Based Strategies
Information on how replacement and desired behaviors will be reinforced based on identified
student preferences
Information on how staff will respond to the target problem behavior when it occurs
All consequence-based strategies match the function of the target problem behavior
VII. Overall Summary
Reason for referral statement, target problem behavior definition and description
Summary of FACTS and Family-Directed Interview
Summary of ABC Observation and Learning Environment Checklist (LEC)
Statement about the hypothesized function of the behavior
Function-based intervention strategies
VIII. Follow-up data collection
Information on type of data collection procedure to be used to determine efficacy of interventions
