Client:____________________ Structured ABC Data Collection Form (Blank) Therapist:__________________
Adapted from © 1996 The Florida Center on Self Injury Form
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.
Date
Time
Initials
Behavior (specific targets):
1
2
3
Location where behavior occurred:
General activities in progress:
+ Rt + Rt - Rt Auto. Rt
Immediate antecedent (A): attention materials escape sensory
Was ignored, walked away from
Leisure item or food removed/denied
Other request denied
Given instruction/prompt to work
Provoked
No change (client alone)
Immediate consequence (C):
Attention, response block, told to stop
Redirected to another area/activity
Leisure item or food given
Work requirement terminated
Nothing was done/ignored
No change (client alone)
TOTAL