ࡱ> XZW` 8bjbj 4Fr $hhhhdD$0$Bh!QF  Ёgh+\0H"CH"H"  $$$D h$$$h$$$ FUNCTIONAL BEHAVIOR ASSESSMENT  Student s Name:  FORMTEXT      SSN:  FORMTEXT      DOB:  FORMTEXT      Grade:  FORMTEXT      Teacher:  FORMTEXT      School:  FORMTEXT      Referring Person:  FORMTEXT      Position:  FORMTEXT      Current Service:  FORMTEXT      Hours/Week:  FORMTEXT      Agencies Involved:  FORMTEXT      Today s Date:  FORMTEXT  DATE \@ "M/d/yyyy" 4/24/20064/6/2006 Relevant Medical Information:  FORMTEXT       Relevant Social History:  FORMTEXT       Student Communicates by:  FORMTEXT       List Student s Strengths and Weaknesses: Academic:  FORMTEXT       Social:  FORMTEXT       Describe the Problem Behavior(s):  FORMTEXT       Frequency and Duration of Problem Behavior(s):  FORMTEXT       When and Where does the problem behavior(s) occur?  FORMCHECKBOX  With a certain person? Who?  FORMTEXT        FORMCHECKBOX  Certain area of school? Specify:  FORMTEXT        FORMCHECKBOX  Certain time of day? (e.g. subject, lunch, recess, hall, bathroom) Specify:  FORMTEXT        FORMCHECKBOX  Certain activity? (e.g. whole vs. small group, seatwork, transition) Specify:  FORMTEXT        FORMCHECKBOX  In response to dir<>@B`bdxz|  øø}qøc}øjhbUhQ^Uh?h5CJaJ hbUhjhbUhQ^U jhbUh?UmHnHuj6hbUhQ^U hbUh?jhbUh?UhbUh?5hbUh5h5CJ aJ jh?h?5CJ UaJ hx5CJ aJ hX5CJ aJ #>B& o~kd4$$IfTl0) ' t00*644 laT $Ifgd$a$gd8   " $ & ( 8 : < P R T ^ ` b p r t    " $ & F º櫝κ櫏º櫁κsºjJhbUhQ^UjhbUhQ^UjhbUhQ^UjXhbUhQ^U hbUh?hbUh?5hbUh5h?h5CJaJ hbUh jhbUh?UmHnHujhbUh?UjNhbUhQ^U-& ( b ww $Ifgd~kd$$IfTl0) ' t00*644 laT $ ww $Ifgd~kd@$$IfTl0) ' t00*644 laT$ & p ww $Ifgd~kd$$IfTl0) ' t00*644 laTF H J ^ ` b l n p    2 4 \ ^ p r t v 쿷쿝쿷xl쿝hbUh?mHnHujJ hbUhQ^UhXmHnHuj hbUhQ^Uh?h5CJaJjhbUhQ^UhbUh5 hbUh jhbUh?UmHnHujVhbUhQ^U hbUh?jhbUh?UhbUh?5* ww $Ifgd~kd@ $$IfTl0) ' t00*644 laT ( P R {{rrrrrrrrrr0^0gdXgd~kd $$IfTl0) ' t00*644 laT ( * > @ B L N R    , |tb|ZthX!hX5#jR hXhPCJUaJhPhX5"jhXCJUaJmHnHu#j hXhPCJUaJjhXCJUaJhXCJaJ(jhXhXCJUaJmHnHu#jf hXhPCJUaJhXhXCJaJjhXhXCJUaJ hX5 h5   > @ P x z Fnp^8000111T2V2 0^0`gdX0^0gdX, . 0 : < @ P R f h j t v z FH\^`jlp68LNǿǭǿǛǿljǿwe#jhXhPCJUaJ#jhXhPCJUaJ#j*hXhPCJUaJ#j hXhPCJUaJ#j> hXhPCJUaJhPhX5hXCJaJ"jhXCJUaJmHnHujhXCJUaJ#j hXhPCJUaJ'NPZ\^`|~  ٵ٣ّm#jhXhPCJUaJ#j^hXhPCJUaJ#jhXhPCJUaJ#jthXhPCJUaJ#jhXhPCJUaJ#jhXhPCJUaJhXCJaJ"jhXCJUaJmHnHujhXCJUaJ*080:0V0X0Z00000000000114161811111111122ٳ١ُ{i{{W#jhPhPCJUaJ#jhPhPCJUaJjhPCJUaJhPCJaJ#jhXhPCJUaJ#jhXhPCJUaJ#j0hXhPCJUaJ#jhXhPCJUaJUhXCJaJjhXCJUaJ#jHhXhPCJUaJ"ect request or instruction.  FORMCHECKBOX  In response to reprimand.  FORMCHECKBOX  When left alone.  FORMCHECKBOX  When ignored.  FORMCHECKBOX  When denied certain activity/privilege.  FORMCHECKBOX  When routine is changed unexpectedly.  FORMCHECKBOX  Other:  FORMTEXT       Describe what actually happened (the consequences) as a result of the problem behavior(s):  FORMTEXT       As a result of the problem behavior(s), the student: Got: Avoided:  FORMCHECKBOX  Attention  FORMCHECKBOX  Difficult Task  FORMCHECKBOX  Activity/Tangible demand  FORMCHECKBOX  Teacher/Adult  FORMCHECKBOX  Sensory stimulation  FORMCHECKBOX  Certain activity/person Members of Assessment Team Position  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       22,2.2B2D2F2P2R2V2 33"3$3&3032363333334 4&4(4*4J4L4h4j4l44444444we#jhPhPCJUaJ#jPhPhPCJUaJ#jhPhPCJUaJ#jdhPhPCJUaJ#jhPhPCJUaJhPhP5"jhPCJUaJmHnHu#jxhPhPCJUaJhPCJaJjhPCJUaJ'V2 34363333J4455555@667`77 888880^0gdX 0^0`gdP0^0gdP45556585T5V5X555555556666.60626<6>6@6B6V6X6Z6d6f6x6z66666666ڜڜxڜfڜ#jhPhPCJUaJ#jhPhPCJUaJ#jhPhPCJUaJ"jhPCJUaJmHnHu#j(hPhPCJUaJhPhP5#jhPhPCJUaJjhPCJUaJ#j<hPhPCJUaJhPCJaJ(666666666666677777$7&787:7N7P7R7\7^7`7b7v7x7z7777777777777n#jNhPhPCJUaJ#jhPhPCJUaJ#jbhPhPCJUaJ#jhPhPCJUaJ#jvhPhPCJUaJ"jhPCJUaJmHnHujhPCJUaJ#jhPhPCJUaJhPCJaJ+777777788888 8"86888:8D8F8X8Z8n8p8r8|8~888888888888888ǵǣǑm#j hPhPCJUaJ#jhPhPCJUaJ#j&hPhPCJUaJ#jhPhPCJUaJ#j:hPhPCJUaJhPCJaJ"jhPCJUaJmHnHujhPCJUaJ#jhPhPCJUaJ'888 hX5hXhPCJaJ21h:pbU/ =!"#$% 6Dd z  S 0ABD21328_S"bhzwBZy2.XəDDn<zwBZy2.XəPNG  IHDR Þ`PLTEֱ|||wwwDtRNS@f cmPPJCmp0712HsaIDATXG։ DD`wCGG`3)I @ L R \ h n r FFFFFFFFFFFFFFFFFFFG FG FG FG FG G G G G G G FFG G G G G G FFFFFFFFFFFFFFFF8@0(  B S  ?:Text1Text7Text2Text8Text3Text9Text4Text10Text5Text11Text6Text12Text13Text14Text15Text16Text17Text18Text19Check1Text20Check2Text21Check3Text22Check4Text23Check5Check6Check7Check8Check9Check10Check11Text24Text25Check12Check13Check14Check15Check16Check17Text26Text27Text28Text29Text30Text31Text32Text33Text34Text35Text36Text37Text38Text39Text40Text411Jd%EmC$nUiIl&Ss !=Qm - A ] t   !"#$%&'()*+,-./0123456789D]w7W'U6~gy-Y|)6c3Oc # ? S o t t AF!z.Gt 33333333333'BU#6m~Tghy-HYk|)%6Rcr  3;OPcko t t @?&, Ps1`A!X!#_$#%]D&/BU/'t1{m:}=?DPLbUvJV c^^eNgg\gRm4>4z$K5"yH v-'(" Q^wo;J\]g&WLC,x=^5\5d8XP0}s !E^_x8XYt @@Lr pp p ppp0UnknownGz Times New Roman5Symbol3& z Arial"hhä&iä& h h P"24dn n 2HP)?}=*FUNCTIONAL BEHAVIOR ASSESSMENTYour User NameYour User NameOh+'0  $0 P \ ht| FUNCTIONAL BEHAVIOR ASSESSMENTYour User NameFBA.dotYour User Name4Microsoft Office Word@d@@}g@gh ՜.+,0 hp  Crockett County Schoolsn  FUNCTIONAL BEHAVIOR ASSESSMENT Title  !"#%&'()*+,-./012346789:;<=>?@ABCDEFHIJKLMNPQRSTUVYRoot Entry F g[Data $ 1Table5H"WordDocument4FSummaryInformation(GDocumentSummaryInformation8OCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q