2 Untit TD New D2L Mod - Cal Q servi User Pink Pink x mail Q pdf x PDF Cour Para X G - Gra x + C pdffiller.com/jsfiller-desk11/?requestHash=966f769d59653b7a8b91cf2d934f7a83817d81685de9ae812b27fd5b05755661&lang=en&projectId=1376... Update: pdfFiller T La 1 JS 15 I Text Sign Initials Date Cross Check Circle Image Text Box Sticky Erase Highlight Blackout Arrow Line Draw Selection Start free trial DONE Replace text Comments Search Help Feedback Upload new document Edited To the Interviewer. The Functional Analysis Screening Tool (FAST) is designed to identify a number of factors that may influence the occurrence of problem behaviors. It should be used only as an initial screening toll and as part of a comprehensive functional assessment or analysis of problem behavior. The FAST should be administered to several individuals who interact with the person frequently. Results should then be used as the basis for conducting direct observations in several different contexts to verify likely behavioral functions, clarify ambiguous functions, and identify other relevant factors that may not have been included in this instrument. To the Informant: After completing the section on "Informant-Person Relationship," read each of the numbered items carefully. If a statement accurately describes the person's behavior problem, circle "Yes." If not, circle "No." If the behavior problem consists of either self-injurious behavior or "repetitive stereotyped behaviors," begin with Part I. However, if the problem consists of aggression or some other form of socially disruptive behavior, such as property destruction or tantrums, complete only Part II. Informant-Person Relationship Indicate your relationship to the person: How long have you known the person? Parent Teacher/Instructor Residential Staff Other X Do you interact with the person on a daily basis? Years Yes Months No 8 If "Yes," how many hours per day? If "No," how many hours per week? In what situations do you typically observe the person? (Mark all that apply) Self-care routines Leisure activities Part I. Social Influences on Behavior 1. The behavior usually occurs in your presence or in the presence of others 2. Academic skills training Work/vocational training Meals Evenings When (s)he has nothing to do Other: The behavior usually occurs soon after you or others interact with him/her in some way, such as delivering an instruction or reprimand, walking away from (ignoring) the him/her, taking away a "preferred" item, requiring him/her to change activities, talking to someone else in his/her presence, etc. No Yes A 1/2 321% + Fit 3. The behavior ofter is accompanied by other emotional responses, such as velling or crvina Yes T VERSIONS ADD WATERMARK ADD FILLABLE FIELDS 2 Untit TD New D2L Mod - Cal Q servi User Pink Pink x mail Q pdf x PDF Cour Para X G - Gra x + C pdffiller.com/jsfiller-desk11/?requestHash=966f769d59653b7a8b91cf2d934f7a83817d81685de9ae812b27fd5b05755661&lang=en&projectId=1376... Update: pdfFiller T La 1 JS Text Sign Initials 15 Date I R Cross Check Circle Image Text Box Sticky Erase Highlight Blackout Arrow Line Draw Selection Part I. Social Influences on Behavior Start free trial DONE Replace text Comments Search Help Feedback Upload new document 1. The behavior usually occurs in your presence or in the presence of others Yes No 2. The behavior usually occurs soon after you or others interact with him/her in some way, such as delivering an instruction or reprimand, walking away from (ignoring) the him/her, taking away a "preferred" item, requiring him/her to change activities, talking to someone else in his/her presence, etc. Yes 3. The behavior ofteri is accompanied by other "emotional" responses, such as yelling or crying Yes No Edited Complete Part II if you answered "Yes" to item 1, 2, or 3. Skip Part II if you answered "No" to all three items in Part I. Part II. Social Reinforcement 4. The behavior often occurs when he/she has not received much attention Yes NO 5. When the behavior occurs, you or others usually respond by interacting with the him/her in some way (e.g., comforting statements, verbal correction or reprimand, response blocking, redirection) Yes NO 6. (S)he often engages in other annoying behaviors that produce attention Yes 7. (S)he frequently approaches you or others and/or initiates social interaction. Yes No 8. The behavior rarely occurs when you give him/her lots of attention Yes NO T 9. The behavior often occurs when you take a particular item away from him/her or when you terminate a preferred leisure activity (If "Yes," identify:_ Yes 10. The behavior often occurs when you inform the person that (s)he cannot have a certain item or cannot engage in a particular activity. (If "Yes," identify:_ Yes 11. When the behavior occurs, you often respond by giving him/her a specific item, such as a favorite toy, food, or some other item. (If "Yes, identify: Yes 12. 13. self-care (S) he often engages in other annoying behaviors that produce access to preferred items or activities. The behavior rarely occurs during training activities or when you place other types of demands on him/her. (If "Yes," identify the activities: _other) Yes Yes academic work 1/2 321% + Fit Adapted from the Florida Center on Self-Injury VERSIONS ADD WATERMARK ADD FILLABLE FIELDS 2 ^ Untit TD New D2L Mod - Cal Q servi User Pink Pink x mail Q pdf x PDF Cour Para X G - Gra x + C pdfFiller T 1 La D pdffiller.com/jsfiller-desk11/?requestHash=966f769d59653b7a8b91cf2d934f7a83817d81685de9ae812b27fd5b05755661&lang=en&projectId=1376... JS 15 I R Text Sign Initials Date Cross Check Circle Image Text Box Sticky Erase Highlight Blackout Arrow Line Draw Selection Edited 14. TT ... Replace text Comments Search Functional Assessment Screening Tool Page 2 The behavior often occurs during training activities or when asked to complete tasks. 15. (S)he often is noncompliant during training activities or when asked to complete tasks. 16. The behavior often occurs when the immediate environment is very noisy or crowed. 17. 18. When the behavior occurs, you often respond by giving him/her brief "break from an ongoing task. The behavior rarely occurs when you place few demands on him/her or when you leave him/her alone. Part III. Nonsocial (Automatic)Reinforcement 19. The behavior occurs frequently when (s)he is alone or unoccupied Help Feedback ] Yes No (es No Yes No Yes Yes Update: Start free trial DONE Upload new document Yes 20. The behavior occurs at relatively high rates regardless of what is going on in his/her immediate surrounding environment Yes No (S)he seems to have few known reinforcers or rarely engages in appropriate object manipulation or "play" behavior. Yes No 22. (S)he is generally unresponsive to social stimulation. Yes 23. (S)he often engages in repetitive, stereotyped behaviors such as body rocking, hand or finger waving, object twirling, mouthing, etc. Yes No 24. When (s)he engages in the behavior, you and others usually respond by doing nothing (i.e., you never or rarely attend to the behavior.) Yes No 25. The behavior seems to occur in cycles. During a high cycle, the behavior occurs frequently and is extremely difficult to interrupt. During a "low" cycle the behavior rarely occurs. Yes They wou 26. The behavior seems to occur more often when the person is ill. Yes 27. (S) he has a history of recurrent illness (e.g., ear or sinus infections, allergies, dermatitis). Yes NO 2 /2 321% + Fit 1111116111) VERSIONS ADD WATERMARK ADD FILLABLE FIELDS Untit TD New D2L Mod - Cal Q servi User Pink Pink x mail Q pdf x PDF Cour Para X G - Gra x + C pdfFiller T 1 2 ^ La D Edited TT pdffiller.com/jsfiller-desk11/?requestHash=966f769d59653b7a8b91cf2d934f7a83817d81685de9ae812b27fd5b05755661&lang=en&projectId=1376... JS 15 I R Text Sign Initials Date Cross Check Circle Image Text Box Sticky Erase Highlight Blackout Arrow Line Draw Selection Replace text Comments Search Help Feedback Scoring Summary Circle the items answered "Yes." If you completed only Part II, also circle items 1, 2, and 3 Likely Maintaining Variable 2 3 4 5 78 Social Reinforcement (attention) 1 2 3 9 10 11 12 13 Social Reinforcement (access to specific activities/items) ... 1 2 3 1 15 16 17 18 19 21 22 19 20 24 25 26 27 Social Reinforcement (escape) Automatic Reinforcement (sensory stimulation) Automatic Reinforcement (pain attenuation) Comments/Notes: 2/2 321% + Fit ] Update: Start free trial DONE Upload new document 14. The actutes a 34 in the behavior, you and ong nthing a 99111 19 119 911 5 110010 00011 VERSIONS ADD WATERMARK ADD FILLABLE FIELDS AutoSave Module 4 - Functional Assessment B0 Home Insert Draw Design Layout References Mailings Review View Tell me Comments Editing Share Cover Page SmartArt Get Add-ins W # A AA= Blank Page Page Break Chart Table Pictures Shapes Icons 3D Models My Add-ins v Wikipedia Media Links Comment Header Footer Screenshot Page Number Text Box Word Art Drop Cap Equation Advanced Symbol DachyroUNTU MOmativn Interviews - Check for each interview conducted. Attach a summary of each interview to this document. - X Parent or Guardian X - Client - Teacher X Other significant adult - Other significant adult Client Reports Reviewed - Check for each report reviewed. Attach a brief summary for each to this document. - Observational Assessments - Psychological/Psychiatric Assessment - Individualized Education Plan - Other - Please list: Behavioral Information (attach all charts) Description of behavior of concern: Fred stomped his feet during science class. Settings in which the behavior occurs: This occurs throughout his scientific classes at school with his teacher. It goes on to say that the behavior occurs during science class during lunch when a classmate inquires about his science class. Page 1 of 3 599 words English (United States) Accessibility: Good to go + 122% Focus AutoSave Module 4 - Functional Assessment BD Home Insert Draw Design Layout References Mailings Review View Tell me Comments Editing Share Cover Page SmartArt Get Add-ins W # A AA= Blank Page Page Break Chart Table Pictures Shapes Icons 3D My Add-ins v Wikipedia Media Links Comment Header Footer Page Text Box Word Art Models Screenshot Number Drop Cap Equation Advanced Symbol Frequency of behavior (how often): Over the last five days, the behavior has occurred ten times. Intensity of behavior (how severe)? Although the behavior does not offer immediate safety threats, its frequency and emotional responses in students and the teacher indicate a moderate to severe disruption and impact on the classroom environment. Duration of behavior (long long): When Fred stomps his feet in science class, he usually improves quickly, within a few seconds, and is usually over in less than three minutes. Antecedents: The teacher is explaining a new experiment that the class will be conducting. His classmate asks him what he learned about the experiment during their first period. The teacher asked the class if they had an idea about the solar system. The teacher gave the class 15 minutes to review as they had recitation at 8:45 a.m. before the next week's exam. A classmate asked him how his recitation went during their first subject. The teacher announced that they didn't have class in English and Health subject as they were in the Gym this afternoon for the meet and greet of the candidates running for the student council and the election tomorrow. The teacher announced that they had another experiment next week. Behavior: Stomping his feet during science class. Consequences: The teacher paused the explanation addressed him and focused on the lesson. His classmate asked him to stop as he was not comfortable when he was doing it. The whole class looked at him. Classmates rolled their eyes on him. Classmates left him alone in the cafeteria. Teacher stops him, and his classmates look at him curiously. Teacher tells him she needs to talk to his parents, Martha and Jonathan. Page 2 of 3 599 words English (United States) Accessibility: Good to go + 122% Focus Module 4 - Functional Assessment B0 Home Insert Draw Design Layout References Mailings Review View Tell me Comments Editing Share Cover Page SmartArt Get Add-ins W # A AA= N Blank Page Page Break Chart Table Pictures Shapes Icons 3D Models My Add-ins v Wikipedia Media Links Comment Header Footer Page Text Box Word Art Screenshot Number Drop Cap Equation Advanced Symbol AutoSave Hypothesis (es): Fred's behavior of stomping his feet during science class may be a reaction to various antecedents. Fred's behavior might be an attempt to gain attention from his teacher and classmates. When he stomps his feet, the teacher stops her explanation, classmates look at him, and a classmate asks him to stop, which may provide the attention he seeks. Fred's behavior could respond to anxiety or discomfort related to the subject matter or class activities. The antecedents, such as new experiments, questions from classmates, and upcoming recitations, might trigger his anxiety. Stomping his feet might be Fred's way of communicating his frustration or disapproval with the ongoing class activities or subjects. The behavior serves as a non-verbal expression of his feelings. Fred's behavior could be related to sensory sensitivities, where the stimulation from the science class environment, including explanations and interactions with classmates, overwhelms him. Stomping his feet may be a self-regulatory response to this sensory overload. Signature of Staff Signature of Supervisor Page 3 of 3 599 words English (United States) Accessibility: Good to go Focus + 122% AutoSave Home Insert Draw Design Margins Orientation W= Functional Assessment - CASE - Saved Layout References Mailings Review View Picture Format Tell me 1- Indent Spacing Line Numbers Left: Before: Size Columns Breaks a- bc Hyphenation Right: After: D Position Wrap Text Bring Send Selection Align Group Rotate Forward Backward Pane Behavior(s) of concern: stomping his feet during science class Setting: Date/Time Day 1 October 2, Monday 8:45 A.M Day 1 October 2, Monday 12:30 P.M Day 2 October 3, Tuesday 1:30 P.M Day 3 October 4, Wednesday 8:30 A.M Day 3 October 4, Wednesday 11:30 A.M Day 4 October 5, Thursday 8:50 A.M Day 4 Classroom/School Antecedent Mrs. Anderson is explaining a new experiment that the class will be conducting His classmate asks him what he learned about the experiment during their first period Mrs. Anderson asked the class if they had an idea about the solar system Mrs. Anderson gave the class 15 minutes to review as they had recitation at 8:45 a.m. before their next week's exam Fred's classmate asked him how his recitation went during their first subject Mrs. Anderson announced that they didn't have class in English and Health subject as they were in the Gym this afternoon for the meet and greet of the candidates running for the student council and the election tomorrow Behavior Fred starts to stomp on his feet loudly and rhythmically under his desk. Fred stomps his feet. Fred started to stomp his feet loudly. Mrs. Anderson asked Fred to stop stomping his feet thrice as his classmates cannot recite when he does it. Fred started to stomp his feet loudly Fred starts stomping his feet again. Consequence Mrs. Anderson pauses the explanation and addresses Fred, asking him to stop stomping his feet and focus on the lesson His classmate asks him to stop as he is not comfortable when Fred is doing it. The whole class looked at him. Fred's classmates rolled their eyes on him. His classmate left him alone in the cafeteria. Mrs. Anderson stops him, and his classmates look at him curiously. October 5, Thursday 9:20 A.M Mrs. Anderson announced that they had another experiment next week. Fred starts stomping his feet. Mrs. Anderson tells him she needs to talk to his parents, Martha and Jonathan. twice Comments > Editing Share Page 3 of 3 687 words English (Canada) Accessibility: Investigate Focus E + 161%