Functional Behavior Assessment Staff Interview Form

Student & Site: Person Completing Form:

Relationship to Student: Date:
The information requested in this interview will be used to generate a Positive Behavior Support Plan. It will not be used to evaluate the performance
of staff members or parents. We appreciate your time effort and thought in completing it. All responses will be kept confidential and the final plan
will be available only to parents and staff who interact directly with this student.
1. Please identify & describe behaviors you are concerned about in the table below:
Behavior How How long How Where does When does What is Who is with
often? does the severe? the behavior the behavior happening your child
behavior High,Medium, happen? happen? when the when
last? or Low behavior behavior
occurs? happens?
Screaming
Yelling
Swearing
Hitting,
kicking or
pushing
adults
Hitting,
kicking or
pushing
other kids
Biting

Spitting

Throwing

Tipping
Furniture
Sweeping
Surfaces
Sexualized
behaviors
Drops to
floor
Self Abuse

Destroys
property
Other:

Other:

2. What may be reinforcing the behavior? (Please choose 3 high frequency problem behaviors and 2 high frequency positive
behaviors.)
When problem behavior Classroom staff usually Other kids usually Other adults usually
listed below occurs: respond by: respond by: respond by:
Michael J. Delaney, 10/07 Head Start Behavior Procedures, page 1
1.

2.

3.

When positive behavior Classroom staff usually Other kids usually Other adults usually
listed below occurs respond by: respond by: respond by:
1.

2.

3. Please complete the chart below for sensory issues that appear to affect the child?
Area Sensitivity to: Excessive Describe behavior Strategies tried, were
interest in: they successful?
Vision

Hearing

Touch

Taste

Smell

Sense of
body in
space (whole
body response)
4. Communication
Receptive: I estimate the student understands about % of what is said to him/her in his/her native
language ( ) and about % of what is said in English. Please rate the following
strategies that may support the child’s understanding of spoken communication and how important you
think it is for the child:
Communicative Strategy Required Helpful Not Needed
Communication to child is kept short & simple
Limit directions to: One Step
Two Steps
Three Steps
Michael J. Delaney, 10/07 Head Start Behavior Procedures, page 2
Provide gestures, obvious cues in facial expression
Provide photo/picture drawing prompts
Use sign language
Model desired behavior
Provide physical prompts-support throughout activity
Hand over hand support to learn new routines
Other:

Expressive: How does the child express needs, wants or feelings; respond to directions & answer questions?
Communication behavior Frequently Often Sometimes Seldom Never
Crying, whining, fussing
Socially inappropriate behavior (what?)
Aggressive behavior (what?)

Pulls adult towards object/area

Brings stuff to adult
Points
Uses communication device
Uses signs
Uses pictures or photographs
Speaks Partially understandable
with phrases, unrelated to context
Partially understandable
phrases, related to context
Understandable, unrelated
phrases
Understandable,
phrases/sentences related to
context
Other strategy:

5. Please write your thoughts about how difficulty with communication may be impacting the child’s behavior:

6. Identify what you think the child is trying to get, avoid, or tell you with the problem behavior and suggest
ways you would rather see him/her get the same outcome:
When child He/She is or Or The child could achieve this outcome by:
behaves this way: trying to AVOID: TELL (write 2 better ways the child could get, avoid or tell you
(write behavior below) GET: YOU: the same thing in a way you could approve of)
1)

2)
Michael J. Delaney, 10/07 Head Start Behavior Procedures, page 3
 1)

2)

1)

2)

7. What have you seen the child do (at least sometimes) that is a positive first step toward the positive behaviors
you listed above?

8. Considering the child’s physical and cognitive skills, what could we teach him/her so he/she could meet
his/her needs without using problem behaviors?

9. How have you tried to deal or cope with this behavior in the past? What has been successful, what has been
unsuccessful?
What you tried: What part worked? What didn’t work?

Michael J. Delaney, 10/07 Head Start Behavior Procedures, page 4

10. What medications is the child taking (if any), do they impact behavior?

11. What physical or medical issues (if any) does the child have that may affect him/her? (e.g., asthma,
allergies, rashes, sinus infections, seizures)

12. Describe the child’s sleeping patterns, & report to what extent they impact his/her behavior?

13. Describe the child’s eating routines & diet, and the think hunger, food compulsions, food odors or
discomfort in the digestive system may affect his/her behavior.

14. Mark conditions in your child’s life that may be a “set up” for problem behaviors to happen, and list
how frequently they have happened over the past year (estimate):
Setting bad little meds bus change other other other other
Events night, or or no change issues or
Ongoing poor break- &/or conflict at
issues or sleep fast issue home
things that How
lead to How How How frequent:
How How How How
problem How frequent: frequent: frequent: frequent:
frequent: frequent: frequent:
behavior frequent:
Trigger high low time is peer change not Has does other
Event demands atten- not issues or clear or to do not like
which struc- transi- conflict in some- an
occurred
tion expecta- thing activity
tured ions
right tions he/she What How
before the How doesn’t activity? frequent:
frequent:
behavior How How How How want to
happened How frequent:
frequent: frequent: frequent: do How
frequent: frequent:
How
frequent:
15. Based on your classroom rules, please describe your expectations for this child’s behavior at this time:

Michael J. Delaney, 10/07 Head Start Behavior Procedures, page 5

16. What chores does the child do in the classroom? Does he/she take responsibility for his/her own things?

17. How many people interact with the child in class? Do you believe these interactions affect the child’s mood
or behavior? Does he/she have friends?

18. What talents, interests or hobbies does the child have?

19. What activities, events, people or things does the child like?

20. Please describe your hopes and dreams for the child’s future after preschool services conclude. Include what
community activities you see the child involved in:

Michael J. Delaney, 10/07 Head Start Behavior Procedures, page 6

21. Additional comments/input:

Thank you for the time and effort put into completing this document!

Michael J. Delaney, 10/07 Head Start Behavior Procedures, page 7