FBA Questionnarie.docx

Problem Behavior Questionnaire1

Student: ___________________________________ Grade: _____ Sex: M F IEP: Y N

Teacher: ___________________________________ School: __________________________________

Person Filling out Form: ___________________________________

Relationship to Student: ____________________________________

Briefly describe the problem behavior(s):

Directions: Think of a typical episode of problem behavior. Circle the frequency at which each of the following statements is true.

	0%	10%	25%	50%	75%	90%	100%
1. How often does the problem behavior occur and persist when you make a request to perform a task?	0	1	2	3	4	5	6
2. How often does the problem behavior stop when you redirect the student to get back on task or follow the rules?	0	1	2	3	4	5	6
3. When the student engages in the problem behavior with peers, how often do peers leave them alone?	0	1	2	3	4	5	6
4. When the student engages in the problem behavior, how often do peers verbally respond or laugh?	0	1	2	3	4	5	6
5. How often does the conflict occur outside the classroom? (i.e. recess or on the bus)	0	1	2	3	4	5	6
6. How often does the conflict occur when you are helping other students?	0	1	2	3	4	5	6
7. How often does the conflict occur in the presence of specific peers?	0	1	2	3	4	5	6
8. How often does the conflict occur following an earlier episode?	0	1	2	3	4	5	6
9. How often does the problem behavior occur during specific academic activities?	0	1	2	3	4	5	6
10. How often does the problem behavior stop when peers stop interacting with the student?	0	1	2	3	4	5	6
11. How often does the problem behavior occur when peers are paying attention to other students?	0	1	2	3	4	5	6
12. How often does the problem behavior stop when you provide 1:1 instruction to get the student?	0	1	2	3	4	5	6
13. How often does the student stop the problem behavior if you stop making requests or end the activity?	0	1	2	3	4	5	6
14. How often does the problem behavior stop when peers move away from the student?	0	1	2	3	4	5	6
15. How often does the problem behavior occur following unscheduled events or disruptions to classroom routine?	0	1	2	3	4	5	6

Additional Information:

When does the problem behavior occur most? During what activities or at what times do you have the most trouble with this student?

Where does the behavior occur the most?

How often does the behavior typically occur? (e.g. # per period, daily, weekly)

Have you ever observed the student use appropriate behaviors during times that are typically problematic? If yes, any guesses why?

Do you think the problem behavior is related to an academic skill deficit?

Is there any other information which may be helpful to this child and their behavior?

Problem Behavior Questionnaire Profile

Circle the score given for each question from the scale below the corresponding question number (in bold). Then add up the scores to develop a hypothesis for the problem behavior.

Peers						Adults						Setting Events
Escape			Attention			Escape			Attention			Setting Events
3	10	14	4	7	11	1	9	13	2	6	12	5	8	15
6	6	6	6	6	6	6	6	6	6	6	6	6	6	6
5	5	5	5	5	5	5	5	5	5	5	5	5	5	5
4	4	4	4	4	4	4	4	4	4	4	4	4	4	4
3	3	3	3	3	3	3	3	3	3	3	3	3	3	3
2	2	2	2	2	2	2	2	2	2	2	2	2	2	2
1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Total __ out of 18			Total __ out of 18			Total __ out of 18			Total __ out of 18			Total __ out of 18

Hypothesis for Problem Behavior: _____________________________________

Source: Lewis, T.J., Scott, T., & Sugai, G. (1994). The problem behavior questionnaire: A teacher based instrument to develop functional hypotheses of problem behavior in general education classrooms. Diagnostique. 19, 103-115.