Functional Assessment Checklist for Teachers and Staff (FACTS-Part A) Problem in Picture Form (Pro-form) Step1 Step 2 Step 3 Student/Grade: Eddie “Shane” McDowell Date: Nov 3, 2005 Interviewer: Ms. Jones, Mr. Stanly, Principal Johnson Respondent(s): Mr. Willson Student Profile: Please identify at least three strengths or contributions the student brings to school. Eddie can be a very pleasant child, he does well in his art class and he is good at sports Problem Behavior(s): Identify problem behaviors __Tardy Fight/Physical Aggression __Unresponsive _Inappropriate Language __Withdrawn __Verbal Harassment __Verbally Inappropriate Disruptive __Insubordination __Work not done __Self-injury __Theft __Vandalism __Other_________________ Describe problem behavior: ___________________________________________________________ Step 4 Identifying Routines: Where, When and With Whom Problem Behaviors are Most Likely. Schedule Activity Likelihood of Problem Specific Problem (Times) Behavior Behavior 8:30 –9:15 Language Low 1 9:15-9:21 Transition Reading 10:05-10:11 Transition Low 10:11-11:03 Math/Science Low 1 1 Lunch Art Transition 3 4 5 2 3 4 5 Threat s swear 6 High Harassment 6 High Threat, Harassment 6 High 2 3 4 5 6 High 2 3 4 5 6 2 3 4 5 6 2 3 4 5 2 3 4 5 High Swear, aggression Threat s swear High Low 1 Step 5 2 Low 1 12:30-12:36 5 Low 1 11:44-12:30 4 Low 1 11:03-11:44 3 Low 1 9:21-10:05 High 2 6 High 6 Select 3-1 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, Todd & Carr (2000) Functional Assessment Checklist for Teachers & Staff (FACTS-Part B) Student/Grade: _Eddie McDowell. _________ Date:______Nov 3, 2005______ Interviewer: Ms. Jones Respondent(s): Mr. Willson, Mr. Stanly, Principal Johnson Routine / Activities / Context: Which routine (only one) from the FACTS-Part A is assessed? Step 1 Step2 Routine/Activities/Context Problem Behavior(s) Academic times Threat, swear, aggression Provide more detail about the problem behavior(s): Step 3 What does the problem behavior(s) look like? Threat/Swear = name calling, sexually Inappropriate comments, loud voice, intimidating gestures How often does the problem behavior(s) occur? Everyday How long does the problem behavior(s) last when it does occur? Arguing/threats continues 3-5 And can lead to fight What is the intensity/level of danger of the problem behavior(s)? teasing- low intensity What are the events that predict when the problem behavior(s) will occur? (Predictors) 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 activities too long _academic failure ________________ __Other _______________________ Step 4 What consequences appear most likely to maintain the problem behavior(s)? Things that are Obtained Things Avoided or Escaped From __adult attention Other:_______________ hard tasks Other:_____________ peer attention _____________________ __reprimands __________________ __preferred activity _____________________ __peer negatives __________________ __money/things _____________________ Step 5 __physical effort __________________ __adult attention __________________ SUMMARY OF BEHAVIOR Step Identify the summary that will be used to build a plan of behavior support. Setting Events & Predictors Problem Behavior(s) Maintaining Consequence(s) 6 Given structured academic (math) situations Step 7 Step 8 Threat Swear Aggression Escape hard tasks How confident are you that the Summary of Behavior is accurate? Not very confident 1 2 3 4 5 Very confident 6 What current efforts have been used to control the problem behavior? Strategies for preventing problem behavior(s) Strategies for responding to problem behavior __Schedual Change __Seating Change __Curriculum Change Other:Precorrect tell him to work & talk nicely __Reprimand Other: send to office __Office Referral _______________________ Detention ________________________ March, Horner, Lewis-Palmer, Brown , Crone, Todd & Carr (2000)