Office for Student Supports and Program ServicesOccupational and Physical Therapy

Physical Therapy Screen Criteria

Child’s Name: ______Student #: ______Date: ______

DOB: ______School :______Grade: ______

ESE Programs: ______504 Teacher: ______

Referred by: ______Explain concern: ______

______

1. Can the child walk up and down curbs without assistance? Describe:

Independent, no hesitation Independent with hesitation

Needs 1 hand assist Inattentive and unsafe

2. Can the student open all the (unlocked) doors on the school campus, including tensioned and non-tensioned doors? Yes No

3. Can the student walk up and down stairs with or without having to hold on to a railing or hold someone's hand? Yes No N/A

4. If the student rides a school bus, can he/she get on and off the bus unassisted? Yes No

5. Is the student able to access all the age-appropriate playground equipment? Yes No

6. When walking about the school campus with his/her class, can the child keep pace with the class? Yes No

If not, can it be attributed to inattention/distractibility or does the child appear to have a physical limitation?

7. Can the student walk without falls on uneven terrain? Yes No

8. Is the student able to sit comfortably on the floor? Yes No

9. Can the student stand up from sitting on the floor without having to hold on to furniture? Yes No

Can the student sit down on the floor without having to hold on to furniture? Yes No

10. Is the student able to carry all his/her materials, including books, backpack and lunch tray? Yes No

11. Does the student have adequate speech volume? Yes No

12. Is the student's endurance adequate for sustained performance throughout the school day? Yes No

13. Does the student have a medical condition that intermittently affects physical performance or mobility? Yes No

14. Does the student actively participate in physical education? Yes No

Please return this form to the Guidance Secretary AND email: Compliance Teacher, Therapist, and Glennda McCallister, Supervisor ESE ()

------THERAPIST ONLY------

Date received by Therapist: ______

Outcomes: Teacher contact date: ______Observation date: ______Parent contact date (optional): ______

______1. Schedule a reevaluation meeting to recommend PT evaluation

2. Not an appropriate referral at this time:

______Classroom suggestions provided ______

______Case Manager to pursue Core Team/Assistive Technology/other resources

______No suggestions necessary

Based on the Considerations for Educationally Relevant Therapy (CERT), Florida Department of Education, Evaluation of Functional Skills in the Educational Environment