Functional Assessment Interview Form

Interviewer: Kait Bateman

Student: D.G.
Respondent(s): K.O.

Date: 2/12/15
Title: 5th grade teacher

1. Describe the behavior of concern: Not doing work/helplessness; complete

shut down when asked to do work; sits at desk, sighs heavily, puts head down. He
has the skills but choses not to do the work; refusal; plays with objects instead of
working, or picks up an unrelated book to read (which he enjoys).
2. How often does the behavior occur? 80% of the day
3. How long does the behavior last? Most of the day
4. How intense is the behavior? Affects his schoolwork and grades; he doesnt
complete his work even with modifications made to it
5. What is happening when the behavior occurs? Anytime there is work to do
independent or group or whole class; writing, math, all subjects; and he doesnt
want to do it
6. When/where is the behavior most/least likely to occur? When theres a written
assignment, when there is anything in which theres an assignment to do (all
subjects)
7. With whom is the behavior most/least likely to occur? Independently, or if he
has to work with someone who he doesnt have a relationship with (ie. when he
was administered his academic evaluations with the special education teacher)
8. What conditions are most likely to precipitate (set off) the behavior?
Having to do work in the classroom
9. How can you tell the behavior is about to start? He puts his head down on his
desk, gives a loud sigh, or mumbles to himself as if he is frustrated. He wont
even get out a piece of paper or workbook that he needs to start.
10. What usually happens after the behavior? Describe what happens according
to adult(s), peers, and student responses. The teacher may come stand by him
and he might look at his workbook or task at hand, the teacher will give him
prompts to start. Peers may try to console him or ask him what is wrong (but
happening less and less now). Teacher may give him options or choices.
Sometimes the teacher will give him space first and not help unless he asks for it
(but he usually doesnt ask). Student teacher may give him more modifications.
Student may continue to be on task or bounce back and become social with
friends, depending on the day/time/task.
11. What is the likely function (intent) of the behavior; that is, why do you think
the student behaves this way? What does the student get or avoid? He gets
adult and peer attention, he gets one-to-one teacher assistance, he gets out of
doing assignments by himself. He has learned helplessness.
12. What behavior(s) might serve the same function (see question 11) for the
student that is appropriate within the social/environmental context? He can
do his work and get praised, which will be good attention for him. When he
comes in with his homework completed, he gets attention from peers and adults
when/if he participates and shares out his answers.

13. What other information might contribute to creating an effective

intervention plan (eg. Under what conditions does the behavior NOT occur?)
Art, specials (except for PE) sometimes; When he gets one-on-one attention,
during independent reading time (but only the actual reading, he wont do the
work that is associated with the reading like writing or answering comprehension
questions about the book).
14. Who should be involved in the planning and implementation of the
intervention plan? Both school psychologist intern and teacher
Other notes:
HW used to be a battle with D, but teacher insists he does it now (he used to not
have to do any HW). She asks him to give it a good try for 20 minutes, and if he
cannot, get it signed by mom and be done with it. Hes been turning it in, and he
gets a free homework pass for every 5 he turns in. He has only used the
homework pass once, and has been turning in his homework But sometimes the
teacher believes that Mom is doing the homework for D. (She always did his
homework for him in years past).
Teacher believes D has learned helplessness. He has the ability to do the work,
just does not want to; refuses; defiance. In some areas (writing in particular) he
lacks the skills, but only because hes refused to do it for so long.
Teacher thinks that maybe D is a perfectionist and wont even try to do it if he
thinks there is a chance hes going to get it wrong?
When he does his homework and shares it with the class, he seems happier and
more outgoing; proud of himself
He used to sit there all day and not even get up to go to the bathroom, wont go to
lunch or recess, wont even move, or talk to friends This is less often now.
He will talk to his teachers more so now than ever before Used to never ask for
help. Now he asks on very little occasion.
If the teacher helps he will give it a try, otherwise he wont. Occasionally the
teacher will start a task for him, but wont finish it for him.
He sits out a lot in PE. Is embarrassed to do the activities?
He is motivated by getting time with friends, and time to read his favorite books.
He is also motivated by animals (anything having to do with animals).
He says he doesnt want to be different from the other kids, yet continues to act
this way.
Teacher is now giving him more options Do X or Y, instead of letting him sit
and refuse to do work.
He is close to proficient in all subjects on last years TCAP.