Cipani EO School Behavioral Interview Form (can be copied by owner of this text with permission for use in FBAs)
Appendices

Rating

H/D/W

Attention EO

When the student requests or demands adult (i.e., instructional staff) attention and is told to wait?

When the student desires attention and the adult is unavailable for such?

When an adult withdraws attention from this student and/or attends to others (classmates, peers)?

When peers or certain classmates are present (vs. the absence of such behaviors when they are not present)?

Rating

H/D/W

Tangible EO-Consumable

When the student requests or demands a desired consumable item and is told to wait?

When the student desires a preferred consumable item and the item is temporarily unavailable (and/or is told “No”)?

When the student desires a preferred consumable item and is given a different item (e.g., redirected)?

When others (classmates, peers) get the consumable item and this student does not?

When the student does not get enough of the consumable item (e.g., wanted two cookies and got only one, finished item and wanted more)?

Rating

H/D/W

Tangible EO-Activity, Event

When the student requests or demands a desired event or activity and is told to wait?

When the student desires a preferred event or activity and such is temporarily unavailable (and/or is told “No”)?

When the student desires a preferred activity or event and is directed to an alternate activity (redirected)?

When others (peers) get the desired activity or event and this student does not?

When the student does not get a sufficient amount of time with the desired activity (e.g., wanted a half hour of computer time and got only 10 minutes; activity ended and student told to transition to a less desired activity)?

Rating

H/D/W

Unpleasant Social Situation EO

When the student is presented with any social or task demand (i.e., problems in compliance to simple adult/teacher instructions)?

When the student is in circumstances that involve following the rules of a game or play activity?

When the student is criticized or corrected during instructional task or chore?

When the student receives social disapproval from an instructional staff person or peer (for behavior, manner of dress, way of talking, etc.)?

When the student receives a negative consequence for his or her behavior or is threatened/warned with one (e.g., is told he or she will lose some free time after lunch for some behavior)?

When the student is interacting with certain peers or instructional staff members?

When the student is in social situations with too many people?

When the student is in social situations with novel people?

When the student is in social situations with a member(s) of the opposite gender?

When the student is in an argument with a peer/friend/other?

When the student is in novel social situations or settings?

Rating

H/D/W

Relatively Difficult Task EO

When the student is presented with instruction, seatwork, or an instructional activity that is relatively difficult (lacks prerequisites or skill in its entirety) for him or her?

When the student is presented with a nonacademic task that is relatively difficult (lacks prerequisites or skill in its entirety) for him or her?

Rating

H/D/W

Relatively Lengthy Task EO

When the student is presented with instruction, seatwork, or an instructional activity that is relatively lengthy (e.g., 1 hour in length when the current duration for active engagement is 10 minutes) for him or her?

When the student is presented with a nonacademic task that is relatively lengthy (e.g., 1 hour in length when the current duration for active engagement is 10 minutes) for him or her?