OP-1 Functional Behavior Assessment (Optional Form) District Name

Child’s Name: Madison Anderson Student ID: 2512674 Grade: 3rd

Date of Meeting: April 25, 2017 Date of Implementation: May 6, 2017

Directions: A functional behavioral assessment (FBA) must be conducted when the IEP team determines that the student’s behavior is a
manifestation of the student’s disability. A FBA may be conducted, as determined appropriate by the student’s IEP team, if the student’s behavior results
in disciplinary action that changes the child’s placement on the continuum of alternative placement options.

Please fill out a separate copy of this form for each behavior being assessed.

1. Behavior of Concern: Provide a description of the behavior in observable and measurable terms. Include a descrption of the intensity,
frequency and duration of the problem behavior.

When Madison is over stimulated by bright lights, loud noise, other students transitioning around her, and/or hears the
word “work,” she makes a fist with her hand and punches herself in the face and/or will stand up, jump, and fall to the
ground, hard enough to bruise her body. Madison will usually punch herself and/or throw herself to the ground for one
to three minutes before she returning the activity she perviously doing.
2. What Event Triggers the Behavior (Antecedent): Include a description of environmental factors which may contribute to the
behavior (e.g., medical conditions, sleep, diet, scheduling and social factors.)

Environmental factors that triger this behavior are bright lights, loud noise, and/or other students transitioning around
Madison. This behavior is part is a response to Madison's Autism. Madison's problem behaviors are also triggered
when she is tired, hungry, and/or is not given her medication.
3. Setting Where Behavior Most Likely Occurs: Describe the setting in which the behavior occurs (time of day, physical setting,
persons involved). Include a description of any relevant events that preceded the target behavior (antecedents).

Madison's problem behavior occurs in the classroom throught the day. There is an increase in problem behavior when
she is tired or hungry but there is no consistant time this behaviors occurs.
4. How Often/How Long: Describe the time between the request to stop or change the behavior and the time of the student’s response to
the request.

There is usually a one to two minute period between the request for Madison to return to her work and her
compliance.
5. Who is the student most likely to react negatively to when requested to do something and who is the
student least likely to react negatively to when requested to do something?

Madison is most likely to react negatively when requested to do something and Anabella is least likely to react
negatively when requested to do something.
6. What is the vocal adult response to the student’s negative behavior?
The classroom teacher speaks in a gentle and soft tone saying phrases like: "you're alright," "I will help you," "we're all
done, lets return to our task."
7. Consequences: Include a description of the consequences that resulted from the behavior of concern.
Madison is usually able to clam herself down and with prompting return to the task she was working on before
engaging in problem behavior. When Madison is not able to calm herself down, the classroom teacher restrains her
and applys comforting pressure to her body while speaking positvely and softly to her.
8. Why (function or purpose of behavior)? What is the student communicationg through the behavior of concern?

Self-stimulating in order to calm anxiety from being over stimulated.

Functional Behavioral Assessment Additional Information*
Other Relevant Information (e.g.,
Behavior History Interventions Attempted Primary Mode of Communication
medical)
Noise cancelling headphones used Sounds, facial expressions, and Madison has been diagonised with
intermittenly, break time on the pointing Autism
computer, and verbal reinforcement.

Prepared by the Ohio Department of Education for optional use. Not an ODE Required form. 1
OP-1 Functional Behavior Assessment (Optional Form) District Name

Signatures:

Prepared by the Ohio Department of Education for optional use. Not an ODE Required form. 2