Directions: (1) Fill in fields on the left side. (2) For each occurrence collect data by recording the date, time, initials and placing checks to identify the behavior (B), location, activity, antecedent (A), & consequence (C). (3) Summarize the (A) & (C) data to identify the likely function. Enter the # of times an A or C was checked under the function headings, by calculating across. Enter totals at the end of each column.-- r - -—x
Date Time Initials			3	■		-	■	;		2 ?	P t	i	-
	■	—			•	■			■				11
													
													
Behavior (specific targets):													
1 NC		•			y	■		>				•	
2													__
3													
Location where behavior occurred:
®
(llAtCrooxA			y		<																
							•														
																					
General activities in progress:																					
			/			■															
■ -																					
																					
																					
																					
Was ignored, walked away from																					
Leisure item or food removed/denied																					
Other request denied																					
Given instruction/prompt to work			~A		v		/			y		y	•								
Provoked																					
No change (client alone)																					
+ Rt    + Rt
attention materials
■ Rt    Auto. Rt
escape sensory
Immediate consequence (C):
Attention, response block, told to stop
Redirected to another area/activity
Leisure item or food given
Work requirement terminated
-Ne-change-trttelTäTöTieT \<yTvevt*-
Nothing was done-fothers present} ^M'J-
TOTAL I    4 I
Adapted from © 1996 The Florida Center on Self Injury Form