Functional Behavioral Assessment (FBA) Report

Student Information

Student Name School Grade Date of Report Evaluator(s)

Reason for Referral

Background Information

Targeted Behaviors

Behavior	Description

Data Collection Methods

Antecedent-Behavior-Consequence (ABC) Analysis

Antecedent	Behavior	Consequence

Summary of Data & Patterns Observed

Hypothesis Statement (Function of Behavior)

Recommendations & Next Steps