Social Skills Checklist (Elementary) - 1 - SOCIAL SKILLS CHECKLIST (Elementary/Pre-K) Name of child: ______________________ Date: _______________________ Birth date: __________________________ Assessor’s name: _______________ Instructions: For each question, check if that particular social skill occurs Almost Always, Often, Sometimes, or Almost Never. RATING SCALE Almost always- the student consistently displays this skill in many settings and with a variety of people Often- the student displays this skill on a few occasions, settings and with a few people Sometimes- the student seldom displays this skill but may demonstrate it on infrequent occasions. Almost Never- the student never or rarely exhibits this skill. It is uncommon to see this in their daily routine. SOCIAL PLAY & EMOTIONAL DEVELOPMENT Almost Always Often Sometimes Almost Never 1.1 Beginning Play Behaviors 1. Maintains proximity to peer within 1 foot 2. Observes peers in play vicinity within 3 feet 3. Parallel play near peers using the same or similar materials (e.g., playing cars near a peer who is also playing cars) 4. Physically imitates peer 5. Verbally imitates peer 6. Takes turns appropriately during simple games 1.2 Intermediate Play Behaviors 1. Shares toys and talks about the activity with peers, even though the play agenda of the other children is different 2. Physically and verbally responds to interactions from peers (accepts toy from peer, answers questions) 3. Returns and initiates greetings with peers 4. Know appropriate ways of joining in an activity with peers 5. Invites others to play 6. Takes turns during structured activities 7. Obeys game rules 8. Requests toys, food, and materials from peers 1.3 Advanced Play Behavior 1. Plays cooperatively with peers during imaginative play 2. Makes comments about what he/she is playing to peers 3. Organizes play (suggests ideas to peers on how to play) 4. Follows peer play plans 5. Takes turns during unstructured activities without a time limit 6. Offers toys, food, and materials to peers Social Skills Checklist (Elementary) - 2 - EMOTIONAL REGULATION Almost Always Often Sometimes Almost Never 2.1 Understanding Emotions 1. Identifies likes and dislikes 2. Identifies emotions in self 3. Identifies emotions on others 4. Justifies emotions once identified (eating because I’m hungry) 5. Demonstrates affection and empathy toward peers 6. Refrains from aggressive behaviors toward peers 7. Refrains from aggressive behaviors toward self 8. Does not exhibit intense fears or phobias 9. Interprets body language 10. Uses different tones of voice to convey messages 2.2 Self Regulation 1. Allows others to comfort him/her if upset or agitated 2. Self regulates when tense or upset 3. Self regulates when energy level is high 4. Deals with being teased in acceptable ways 5. Deals with being left out of a group 6. Accepts not being first at a game or activity 7. Accepts losing at a game without becoming upset/angry 8. Says “no” in a.

1. Social Skills Checklist (Elementary) - 1 -
SOCIAL SKILLS CHECKLIST (Elementary/Pre-K)
Name of child: ______________________ Date: _______________________ Birth date:
__________________________ Assessor’s name: _______________ Instructions: For each
question, check if that particular social skill occurs Almost Always, Often, Sometimes, or
Almost Never.
RATING SCALE Almost always- the student consistently displays this skill in many settings
and with a variety of people
Often- the student displays this skill on a few occasions, settings and with a few people
Sometimes- the student seldom displays this skill but may demonstrate it on infrequent
occasions.
Almost Never- the student never or rarely exhibits this skill. It is uncommon to see this in their
daily routine.
SOCIAL PLAY & EMOTIONAL DEVELOPMENT Almost Always Often Sometimes Almost
Never 1.1 Beginning Play Behaviors
1. Maintains proximity to peer within 1 foot
2. Observes peers in play vicinity within 3 feet
3. Parallel play near peers using the same or similar materials (e.g., playing cars near a peer who
is also playing cars)
4. Physically imitates peer 5. Verbally imitates peer 6. Takes turns appropriately during simple
games
1.2 Intermediate Play Behaviors 1. Shares toys and talks about the activity with peers, even
though the play agenda of the other children is different
2. Physically and verbally responds to interactions from peers (accepts toy from peer, answers
questions)
3. Returns and initiates greetings with peers 4. Know appropriate ways of joining in an activity
with peers 5. Invites others to play 6. Takes turns during structured activities 7. Obeys game
rules 8. Requests toys, food, and materials from peers

2. 1.3 Advanced Play Behavior 1. Plays cooperatively with peers during imaginative play 2. Makes
comments about what he/she is playing to peers 3. Organizes play (suggests ideas to peers on
how to play) 4. Follows peer play plans 5. Takes turns during unstructured activities without a
time
limit
6. Offers toys, food, and materials to peers
Social Skills Checklist (Elementary) - 2 -
EMOTIONAL REGULATION Almost Always Often Sometimes Almost
Never 2.1 Understanding Emotions
1. Identifies likes and dislikes 2. Identifies emotions in self 3. Identifies emotions on others 4.
Justifies emotions once identified (eating because I’m
hungry)
5. Demonstrates affection and empathy toward peers 6. Refrains from aggressive behaviors
toward peers 7. Refrains from aggressive behaviors toward self 8. Does not exhibit intense fears
or phobias 9. Interprets body language 10. Uses different tones of voice to convey messages
2.2 Self Regulation 1. Allows others to comfort him/her if upset or agitated 2. Self regulates
when tense or upset 3. Self regulates when energy level is high 4. Deals with being teased in
acceptable ways 5. Deals with being left out of a group 6. Accepts not being first at a game or
activity 7. Accepts losing at a game without becoming upset/angry 8. Says “no― in
acceptable way to things he/she does not want
to do
9. Accepts being told “no” without becoming upset/angry 10. Able to say “I don’t
know― 11. Able to end conversations appropriately
2.3 Flexibility 1. Accepts making mistakes without becoming upset/angry 2. Accepts
consequences of his/her behavior 3. Accepts unexpected changes 4. Continues to try when
something is difficult 5. Ignores others or situations when it is desirable to do so
2.4 Problem Solving 1. Identifies/defines problems 2. Generates solutions to problems 3. Carries
out solutions by negotiating or compromising 4. Understands impact his/her behavior has on
peers
Social Skills Checklist (Elementary) - 3 -
COMMUNICATION SKILLS Almost Always Often Sometimes Almost

3. Never 3.1 Conversational Skills
1. Initiate conversation when it is appropriate to do so 2. Initiates conversation around specific
topic 3. Asks “Wh” questions 4. Responds to “Wh” questions 5. Makes a variety of
comments, related to the topic during
conversation
6. Introduces him/herself to someone new 7. Introduces people to each other 8. Ends
conversations appropriately
3.2 Nonverbal Conversational Skills 1. Maintains appropriate proximity to conversation partner
2. Orients body toward speaker 3. Pays attention to a person’s nonverbal language and
understands what is being communicated
4. Waits to interject 3.3 Compliments
1. Gives appropriate compliments to peers
2. Appropriately receives compliments
3. Asks for a favor appropriately
4. Apologizes independently
Social Skills Checklist (Elementary) - 4 -
SUMMARY OF SOCIAL SKILLS CHECKLIST
Total % Marked
as Almost Always
Total % Marked as
Often
Total % Marked as Sometimes
Total % Marked as
Almost Never 1.1 Beginning Play Behaviors
1.2 Intermediate Play Behaviors

4. 1.2 Advanced Play Behaviors
2.1 Understanding Emotions
2.2 Self Regulation
2.3 Flexibility
2.4 Problem Solving
3.1 Conversational Skills
3.2 Nonverbal Conversational Skills
3.3 Compliments
Calculation: For each section, calculate the percentage of questions marked as Almost Always,
Often, Sometimes, and Almost Never. To calculate, total the number of questions checked under
the category in that specific section and divide by the total number of questions in the section,
then multiply by 100.
Example: To calculate the total % of components marked “Almost Always― under the
Beginning Play Behaviors section, first total the # of questions checked “Almost Always―
in that section. Then, determine the # of total questions under Beginning Play Behaviors. Divide
the # of questions checked by the total # of questions and then multiply by 100.
________ questions marked “Almost Always― ÷ 6 total questions, x 100 = _______ %
Arkansas State University
College of Education and Behavioral Science
Department of Educational Leadership, Curriculum, and Special Education
Positive Behavior Interventions and Supports Project
Part I: Functional Behavior Assessment
Overview
In this assignment, candidates will selct a student that has been identified with a disability
(student must have IEP) that exhibits ONE of the following social skills deficits: taking turns,
conversational skills, interacting with peers, making positive choices, following directions,
completing tasks/chores, organization and/or transition skills. Students will not address violent
behaviors or work with students who demonstrate aggressive behaviors (hitting, elopement,
profanity).

5. Learning Outcomes
Know and demonstrate professional roles and responsibilities relevant to ethical and legislative
requirements as related to Council of Exceptional Children (CEC) Code of Ethics, professional
certification standards, and confidentiality.
Gather, interpret, and communicate background and assessment information from a variety of
sources to make educational decisions and design individualized instruction.
Administer and analyze appropriate formal and informal assessment to make educational
decisions for exceptional learners.
Understand and adhere to legal and ethical guidelines for assessing, identifying, and monitoring
diverse learners with exceptionalities.
Directions
1. Select a student with an exceptionality that displays a social behavior deficit listed above.
2. Complete parent survey, student survey, motivational assessment, and social skills checkslist.
3. Complete Student Profile Sheet.
4. Complete Student Observation using ABC Chart (2 observations for a minimum of 30
consecutive minutes).
5. Write and turn in to Blackboard a Functional Behavior Analysis paper template with the
completed student profile information, motivational assessment, and social skills checklist).
Candidates will use the template provided that addresses APA formatting (includes a title page,
headers, and page numbers). The paper should be written as a report and not in first person.
a. Summarize the student’s profile.
b. Identify the student’s target behavior
c. Summarize the ABC (state the antecedent, behavior, consequence)
d. Hypothesize the function of the behavior
Functional Behavior Assessment
1. Parent Interview
2. Student Profile Information Sheet

6. 3. ABC Student Observation
4. Student Interview
5. Motivational Assessment
6. Social Skills Checklist
FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA)
PARENT INTERVIEW
Directions: Please complete and return this form to your child’s school. The information will
be used to help develop a
behavior intervention plan for your child. Please return the completed form to
______________________.
Please contact the school/teacher if you have any questions.
Child’s Name ___________________________________________ Age _______
Today’s Date _____________
Address ________________________________________________ Phone
__________________________________
Person completing form ________________________________________ Relationship to child
__________________
Does your child have any medical or physical conditions?
__________________________________________________
List any current medications your child is taking:
_________________________________________________________
Describe your child. (check all that apply)
· easily distracted cooperative talkative angry
· stubborn impulsive shy/quiet friendly
· self-abusive physically aggressive often fidgety shy
· overactive verbally aggressive bossy mean
· moody easy to please cries easily pouts

7. · polite/kind funny/clever prefers to be alone sad
· eager to please others withdrawn sociable passive
Self-concept: Good Fair Poor Relations with parents: Good Fair Poor
Relations with peers: Good Fair Poor Relations with teachers: Good Fair Poor
Relations with sister/brother: Good Fair Poor Accepts responsibility for behavior? Yes No Some
List his/her favorite things to do/places to go:
____________________________________________________________
What motivates your child to behave well?
______________________________________________________________
What usually causes your child to misbehave?
___________________________________________________________
How often does your child misbehave?
_________________________________________________________________
List the specific problem behaviors your child has at home:
_________________________________________________
List the specific problem behaviors your child has at school:
________________________________________________
What efforts have you taken to assist the school in dealing with your child’s behavior?
___________________________
______________________________________________________________________________
__________________
When were you first aware of behavioral problems at school?
______________________________________________
______________________________________________________________________________
__________________
List all community services, doctors, psychologists, social workers, etc that have been helping
with these problems:
Agency Address Phone Number Start/End Date

8. Please attach any additional information you would like the school to consider in planning
a behavior intervention.
Parent/Guardian Signature _______________________________________________
Today’s Date _______________
Functional Behavior Assessment
Student’s Profile Sheet
(Complete ALL Sections)
Student’s Name: _______________________ Exceptionality: ______________________
Grade: ______________________ Date of Birth: _______________________________
1. List behaviors of concern.
2. What does the student do well and when does it occur?
3. What does the student struggle with and when does it occur? Does there appear to be a skill
deficit or do you feel that the student sometimes chooses not to use the skills that they have?
4. What is reinforcing and enjoyable for this student?
5. Are there good days and bad days? If so, does there seem to be a pattern?
6. How does the student communicate his/her needs (verbally, nonverbally, written, etc.)
7. What is his/her learning style (visual, auditory, tactile, kinesthetic)?
8. What type of instruction is the most successful for the student (direct, group/cooperative
learning, lecture, independent/seatwork)?
9. Does academic failure or difficulty with materials appear to produce behaviors?
10. What are settings that negatively affect the behaviors?
11. What are triggers that negatively affect behaviors (lack of social attention, demands/requests,
task transition, setting transition, interruption in routine, negative social interactions, when limits
are set or consequences are imposed, redirected, embarrassment, sleep patterns, eating routines,
medications, health, life stressors, etc.)?
12. What are the warning signs that the student exhibits that indicate that a behavior is about to
occur (restless, withdrawal, loud voice, blurting out, change in mood, etc.).

9. 13. How does the student respond after the behavior has occurred?
14. What interventions/strategies have been used with the student?
15. What consequences have been implemented and which ones have been effective (warnings,
timeouts, ignore behavior, loss of privileges, sent to office, suspension, write-up?
16. Is attendance or tardiness a concern?
FUNCTIONAL BEHAVIORAL ASSESSMENT (FBA))
STUDENT INTERVIEW
Student _________________________________ Date ___________
I have many friends at school Yes No Not Sure
I like coming to school Yes No Not Sure
My classmates like me Yes No Not Sure
I like the other students in my class Yes No Not Sure
I complete my homework most of the time Yes No Not Sure
My parents love me Yes No Not Sure
I get into trouble at school Yes No Not Sure
My home is a happy place Yes No Not Sure
My teachers like me Yes No Not Sure
I get in trouble at home Yes No Not Sure
I get into fights Yes No Not Sure
I have been suspended this year Yes No Not Sure
I have been sent to the office for misbehaving Yes No Not Sure
I usually do what my teacher(s) ask me to do Yes No Not Sure
My classmates tease and pick on me Yes No Not Sure
What do I do that gets me in trouble at school?
___________________________________________________
______________________________________________________________________________
___________
What do I do that gets me in trouble at home?
___________________________________________________
______________________________________________________________________________
___________

10. What would help me to behave better in school?
__________________________________________________
______________________________________________________________________________
___________
What would help me to behave better at home?
___________________________________________________
______________________________________________________________________________
___________
*** IDENTIFYING REWARDS ***
Name 3 things you most like to do at school: Name 3 things you most like to do at home:
1. ______________________________________ 1.
_____________________________________
2. ______________________________________ 2.
_____________________________________
3. ______________________________________ 3.
_____________________________________
Name 3 classmates with whom you would like to work: Name 3 special jobs that you would like
to do at school:
1. ______________________________________ 1.
_____________________________________
2. ______________________________________ 2.
_____________________________________
3. ______________________________________ 3.
_____________________________________
If you had 15 minutes of free-time at school to do what you wanted, what would you do?
________________
ELSE 6163 Positive Behavior Interventions and Supports
Adapted from LCD (6-1-99) 1
1

11. 6
MOTIVATION ASSESSMENT SCALE
Name_______________________________________________
Rater________________________________________ Date___________
Behavior
Description____________________________________________________________________
________________________________
Setting
Description____________________________________________________________________
__________________________________
Instructions: The Motivation Assessment Scale is a questionnaire designed to identify those
situations in which an individual is likely to behave in certain ways. From this information, more
informed decisions can be made concerning the selection of appropriate reinforcers and
treatments. To complete the Motivation Assessment Scale, select one behavior that is of
particular interest. It is important that you identify the behavior very specifically. Aggression, for
example, is not as good as a description as hits his sister. Once you have specified the behavior
to be rated, read each question carefully and circle the number that best describes your
observation of this behavior.
Never=0 Almost Never=1 Seldom=2 Half the Time=3 Usually=4 Almost Always=5 Always=6
1. Would the behavior occur continuously, if this person were left alone for long periods
of time, for example, several hours?
0 1 2
3 4 5
6
2. Does the behavior occur following a request to perform a difficult task?
0 1 2
3 4 5
6
3. Does the behavior seem to occur in response to your talking to another person in the
room?
0 1 2
3 4 5
6
4. Does the behavior ever occur to get a toy, food, or activity that this person has been told
that he or she can’t have?
0 1 2
3 4 5
6
5. Would the behavior occur repeatedly in the same way for very long periods of time if
no one were around, for example rocking back and forth for over an hour?
0 1 2
3 4 5
6
6. Does the behavior occur when any request is made of this person?
0 1 2
3 4 5
6
7. Does the behavior occur whenever you stop attending to this person? 0 1 2

12. 3 4 5
6
8. Does the behavior occur when you take away a favorite toy, food, or activity?
0 1 2
3 4 5
6
9. Does it appear to you that this person enjoys performing the behavior? (It feels, tastes,
looks, smells, and sounds pleasing.)
0 1 2
3 4 5
6
10. Does this person seem to do the behavior to upset or annoy you when you are trying to
get him or her to do what you ask?
0 1 2
3 4 5
6
11. Does this person seem to do the behavior to upset or annoy you when you are not
paying attention to him or her, for example, if you are sitting in a separate room,
interacting with another person?
0 1 2
3 4 5
6
12. Does the behavior stop occurring shortly after you give this person the toy, food, or
activity he or she has requested?
0 1 2
3 4 5
6
13. When the behavior is occurring does this person seem calm and unaware of anything
else going on around him or her?
0 1 2
3 4 5
6
14. Does the behavior stop occurring shortly after (one to five minutes) you stop working
or making demands of this person?
0 1 2
3 4 5
6
15. Does this person seem to do the behavior to get you to spend some time with him or
her?
0 1 2
3 4 5
6
16. Does this behavior seem to occur when this person has been told that he or she
can’t do something he or she had wanted to do?
0 1 2
3 4 5
6
Scoring Sheet
Sensory Escape Attention Tangible
1. 2. 3. 4.
5. 6. 7. 8.
9. 10. 11. 12.
13. 14. 15. 16.
Total Score
Mean Score
Relative Ranking
INSTRUCTIONS FOR USING THE MOTIVATION ASSESSMENT SCALE

13. Person filling out the form had to be familiar with the individual who has the behavior challenge.
To direct our understanding of the behavior challenge to the intent of the challenge versus the
way it appears or make use feel. To understand the correlation between the frequency of the
challenging behavior and it’s potential for multiple intents. To identify those situations in
which an individual is likely to behave in certain ways for example, placing work demands often
leads to head banging. OUTCOMES: To assist in the identification of the motivation(s) of a
specific behavior. From: Duran, V.M. & Crimmins, D.B. (1988). Identifying the variables
maintaining self-injurious behavior. Journal of Autism and Developmental Disorders, 18, 99-
117. Adapted by J.M. Cafiero
SAMPLE A-B-C Recording Form
Date: _____ 6/30/2020 _______Location: _ ___ 3 rd grade general education classroom _____
Observer’s name ___ Exemplary Candidate Length of time observed: __ 30 minutes _
Date /
Time
8/26/15
Antecedent Behavior Consequence
8:00-
8:05
Setting: class had
transitioned into classroom
from morning meeting.
Students sitting at tables for
read to self while teacher
takes attendance and takes
care of morning business
Sitting quietly at table drawing
with colored pencils from a
book of cartoon characters
Teacher redirects to read
to self. Suggests Tony
pick another of his books.
8:05-
8:10
Setting: same
Teacher redirected and went
back to the front of class.
Tony knelt on floor next to
chair at his table and continued
to quietly draw from his book.
Other student at his table
looks up from their
reading and watches him
for a few seconds then
goes back to reading.
8:10-
8:15
Setting: same
Other student at his table
starts to arrange her area
instead of
reading
Tony stops drawing to watch
peer.
Begins to talk to peer quietly.
Peer redirects him and
tells him to stop talking.
8:15-
8:20
Setting: same
Continued read to self.
Classroom continues to be
quiet with majority of
students on task with a few
Tony continues to draw with
colored pencils now with book
closed. (8:15)
Tony continues to draw after
Teacher redirects while
walking past to the door
Teacher redirects him
again to read to self

14. students off task redirection (8:16)
Tony stops drawing and
watches peer at table play with
hair while reading (8:17)
.Teacher comes over to
table, removes drawing,
book and puts colored
pencils back in center
table
Tony’s head is down on the
table with an upset face (8:19)
storage. Quietly talks to
Tony about Read to Self-
expectations. Picks out a
book from his box for him
and directs him to read
quietly to self.
8:20-
8:25
Setting: same read to self-
time. Teacher is walking
around room and preparing
for next activity. Students
are still at tables.
At about 8:24 teacher
directs students to
“find a good place to
stop in their reading―
Tony’s head is still on table
(8:22)
Tony sits up. He is still
frowning and his eye brows are
knitted.
Tony begins to rearrange
colored pencils in the center
storage area.
Tony picks up his book and
begins to flip the pages then
stops when teacher directs to
close books
No response from teacher
or table mates.
No response from teacher
or table mates.
Table mate watches him
for a few seconds
and returns to reading.
No response from teacher
or table mates.
8:25-
8:30
Teacher gives directions to
clear table and put baskets
under chairs and then turn
chairs towards front for
smart board activity.
Tony follows directions and
turns chair. Listens with eyes on
teacher and sitting still. After a
minute, Tony picks up his chair
while still under his bottom and
moves to the other side of his
table closer to the front of the
room.
No response from teacher
or students.
Functional
Behavior
Assessment
Rubric
Standards
Exemplary
15 points
Acceptable
13 points
Unacceptable
10
Summary of
Student Profile
Information
Candidate describes the
student’s demographic
and background
information that includes
Candidate describes the
student’s
demographic and
background
Candidate fails to provide
a description of the
student’s demographic
and background

15. relevant cultural and
familial information that is
related to the target
learner’s educational
needs and abilities that
supports the need for the
development of
interventions with positive
behavior supports.
information, including
pertinent cultural and
familial information,
related to the target
learner’s
educational needs and
abilities.
information that relates to
the learner’s
educational needs.
Candidate also does not
justify the need for the
development of
interventions with positive
behavior supports.
Completed
Assessment(s)
and Interviews
Clearly and accurately
summarized all completed
the Social Skills Checklist
and Motivational
Assessment Scale and
parent and student
interviews. Completed
assessments and interviews
are uploaded to
Blackboard.
Vaguely or inaccurately
completed the Social
Skills Checklist and
Motivational
Assessment Scale and
parent and student
interviews. Completed
assessments and
interviews are uploaded
to Blackboard.
Unclearly completed the
Social Skills Checklist
and Motivational
Assessment Scale and
parent and student
interviews and or fails to
upload Completed
assessments and
interviews to Blackboard.
Target
Behavior
The candidate identifies the
student’s target
behavior that is observable,
measurable, and includes
examples and non-
examples of the behavior.
The candidate identifies
a target behavior that is
observable but does not
include examples and
non-examples of the
behavior.
The candidate does not
identify a target behavior
that is observable and/or
does not include examples
and non-examples of the
behavior.
ABC
Recording
The candidate provides a
collection of student’s
behavior using observation
notes; antecedents,
behavior, and
consequences are
defined with action words
without the use of feelings,
intentions, or inferences.
The candidate provides
a collection of behavior
notes using observation;
antecedents, behavior,
and consequences
however, behaviors are
defined with the use of
feelings or inferences
such as aggressive,
angry, happy, excited,
or lazy.
The candidate does not
provide a collection of
student behaviors using
either observation notes or
antecedents, behavior, or
consequences.
ABC
Summary
Statement
The candidate identifies a
hypothesis in one complete
statement; the behavior
listed in the hypothesis is
the same one identified as
the focus of the FBA, and
all three components
(antecedent, behavior,
consequence) are linked to
The candidate identifies
the hypothesis in a
statement that includes
the antecedent,
behavior, and
consequence; however,
one does not link to the
FBA data.
Candidate does not
identify a hypothesis
statement or the statement
written only links one
component (antecedent,
consequence, behavior) to
the FBA data.

16. the FBA data.
Function of
Behavior
The candidate identifies a
function of the behavior
that is valid, supported in
research literature, and
linked to FBA data.
The candidate identifies
the function of the
behavior that is valid
and supported in
research literature but is
not linked to FBA data.
Candidate fails to identify
function of the behavior
that is related to the
observations conducted.
Exemplary
10 points
Acceptable
8 points
Unacceptable
6 points
Overall
Writing
Guidelines
Candidate demonstrates
professional writing that
adheres to APA format and
is free of errors in spelling,
grammar, and punctuation
Candidate demonstrates
professional writing that
adheres to APA format;
however, there are 5 or
less errors noted in
format, spelling,
grammar, and
punctuation.
Candidate demonstrates
inadequate professional
writing skills that does not
adhere to APA format
AND more than 5 errors
noted in format, spelling,
grammar, and
punctuation.
Part I: Functional Behavior Assessment
Summary of Student Profile Information
Name:
Date of Birth:
Grade:
Exceptionality:
Summary of 16 questions from Student Profile Information
Parent and Student Interviews
Provide a detailed summary of the parent and student interviews
Summary of Results of Social Skill Checklist and Motivation Assessment Scale
Target Behavior
State the behavior that you want to increase or decrease in one sentence
ABC Charts
Observation 1
A-B-C Recording Form
Date: _____________________Location: ____________________________________

17. Observer’s name _____________________________Length of time observed: ___________
Date / Time Antecedent Behavior Consequence
Observation 2
A-B-C Recording Form
Date: _____________________Location: ____________________________________
Observer’s name _____________________________Length of time observed: ___________
Date / Time Antecedent Behavior Consequence
Antecedent, Behavior, Consequence Summary Statement
1. The antecedent is…..
2. The behavior is……
3. The consequence….
Function of the behavior
Based on the ABC charts provided and the results of the Behavior Rating Scale the function of
the behavior is……