# PTR-YC Functional Behavioral Assessment Checklist: Prevent

**Challenging behavior:** ____  **Person responding:** ____  **Child:** ____

| 1. Are there times of the day when challenging behavior is most likely to occur? If yes, what are they? |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Morning | Afternoon | Before meals | Evening |  | During meals | Naptime |  |
| After meals |  | Preparing meals | Other: |  |  |  |  |
| 2. Are there times of the day when challenging behavior is least likely to occur? If yes, what are they? |  |  |  |  |  |  |  |
| Morning | Afternoon | Before meals | Evening |  | During meals | Naptime |  |
| After meals |  | Preparing meals | Other: |  |  |  |  |
| 3. Are there specific activities when challenging behavior is very likely to occur? If yes, what are they? |  |  |  |  |  |  |  |
| Arrival | Dismissal | Large-group times | Small-group times | Naptime | Toileting/diapering | Special event (specify) |  |
| Peer interactions | Centers/free play | Meals | Snack | Transitions (specify) |  |  |  |
| Other: |  |  |  |  |  |  |  |
| 4. Are there specific activities when challenging behavior is least likely to occur? What are they? |  |  |  |  |  |  |  |
| Arrival | Dismissal | Large-group times | Small-group times | Naptime | Toileting/diapering | Special event (specify) |  |
| Peer interactions | Centers/free play | Meals | Snack | Transitions (specify) |  |  |  |
| Other: |  |  |  |  |  |  |  |
| 5. Are there other children or adults whose proximity is associated with a high likelihood of challenging behavior? If so, who are they? |  |  |  |  |  |  |  |
| Siblings | Family member(s) | Care provider(s) | Other adults | Specify: |  |  |  |
| Teacher | Parent | Other children (specify) |  |  |  |  |  |
| Other: |  |  |  |  |  |  |  |
| 6. Are there other children or adults whose proximity is associated with a low likelihood of challenging behavior? If so, who are they? |  |  |  |  |  |  |  |
| Siblings | Family member(s) | Care provider(s) | Other adults | Specify: |  |  |  |
| Teacher | Parent | Other children (specify) |  |  |  |  |  |
| Other: |  |  |  |  |  |  |  |

---

| 7. Are there specific circumstances that are associated with the treatment? |  |
| --- | --- |
| ___Asked to do something | ___Seated for meal |
| ___Given a direction | ___Playing with others |
| ___Reprimand or correction | ___Sharing |
| ___Being told “no” | ___Taking turns |
| ___Sitting near specific peer | ___Playing by self |
| ___Change in schedule | ___Novel/new task |
| ___Getting peer/adult attention | ___One-to-one time with adult |
| Other: |  |
| 8. Are there conditions in the physical environment that affect behavior (e.g., too warm, too cold, too crowded, too hot)? |  |
| ___Yes (specify) | ___No |
| 9. Are there circumstances that occur on some days that are more likely? |  |
| ___Illness | ___No medication |
| ___Allergies | ___Change in medication |
| ___Physical condition | ___Hunger |
| ___Change in diet | ___Parties or social event |
| Other: |  |
| Additional comments not addressed: |  |

| with a high likelihood of challenging behavior? |  |
| --- | --- |
| Transition | End of preferred activity |
| Removal of preferred item | Beginning of non-preferred activity |
| Activity becomes too long | Structured time |
| Unstructured time | Down time (no task specified) |
| Teacher is attending to someone else | During a non-preferred activity |
|  |  |
| What are associated with a high likelihood of challenging (so much noise, too chaotic, weather conditions)? |  |
|  |  |
| Not other days that may make challenging behavior |  |
| Change in caregiver | Fatigue |
| Change in routine | Parent not home |
| Home conflict | Sleep deprivation |
| Stayed with noncustodial parent |  |