PHYSICAL PARTICIPATION IN SCHOOL

General Information & Directions

7/14

This form should be completed as part of a pre-referral process. If there are educational motor concerns please go to the Southeast Area Cooperative website to download the appropriate checklists and this cover page. This is not an evaluation, this is simply a set of checklists for you to complete as part of your concerns, this could be done as part of a student assistance team/teacher assistance team process, or a teacher that has observed some things that she/he are concerned about, etc.

  • Educational Motor Concern – Fine Motor
  • School Age – 21
  • Complete this cover page
  • Complete the OT checklist & return to your OT and/or COTA
  • Preschool Age
  • Complete this cover page
  • Complete the Preschool Functional Educational Checklist and return to your OT and/or COTA
  • Educational Motor Concern – Gross Motor
  • School Age – 21
  • Complete this cover page
  • Complete the PT and the Adapted PE Checklist and return to your PT and/or APE teacher
  • Preschool Age
  • Complete this cover page
  • Complete the Preschool Functional Educational Checklist and return to your PT

A student observation will be scheduled within 1-3 weeks. (recommend that the classroom teacher, student assistance team lead, etc. have made a contact with the parent to let them know of your concerns and that you would like to have an observation)

If educational motor concerns are observed, a recommendation will be made to the Case Manager for possible evaluation; whether it be OT, PT or APE or any combination, thereof.

Please do not add PT, OT or APE on a Consent to Evaluate until this checklist has been completed and the Case Manager has had a conversation with an OT, PT or APE.

Preschool Functional Educational Checklist

1/14

Student Name: ______DOB: ______Date:______

Parent(s) Name: ______Teacher: ______

District/Building: ______Checklist completed by: ______

Preschool Class: AM _____PM _____Therapist(s): ______

Medical Diagnosis (if any):

Special Equipment: (glasses, orthotics, hearing aids, FM Systems, Paras, etc.)

Best time/location to observe student: ______Best time/location to meet with teachers: ______

Date received by Service Provider: ______

______

AREAS OF CONCERN

_____ Fine Motor _____ Gross Motor_____ Self-Care_____ Sensory-Motor

AREAS OF ELIGIBILITY

(Check the specific areas in which the child initially was eligible as a preschooler with a disability, please check N/A if the child has not been already identified)

_____ AdaptiveBeahvior_____ Cognitive Ability_____ Communication_____ Gross/Fine Motor

_____ Pre-Academic Skills_____ Social/Emotional/Behavioral_____ Hearing_____ Vision_____N/A

Comments/Other Information ______

SPECIFIC CONCERNS

  1. Fine Motor/Hand Use/Tool Use

YesNo Yes No

  1. Does the child use a preferred hand?9. When an object is placed in the child’s hand
  2. Which one? ______will the child grasp the object? ______
  1. Is the child able to isolate the index finger to point? ______10. When an object is presented, does child pick it up and hold it? ______
  2. Is the child able to push down and activate a toy

using the index finger? ______11. When holding an object, will the child transfer

it to the opposite hand? ______

  1. When the child picks up small objects, which12. Does the child use one hand to hold or

of the following grasps are observed? stabilize an object while performing a task

(please check) with the other hand (e.g. stirring, stringing beads,

  1. Raking grasp (uses all fingers to playing musical instruments, putting notebook into

rake objects into palm) ______book bag, holding paper while cutting or writing)? ______

  1. 3-finger grasp (grasp object 13. Does the child use a fisted grasp when holding a

with thumb and 1st & 2nd fingers) ______writing utensil? ______

14. Does the child use a 3-finger grasp (grasp

  1. 2-finger grasp (grasp object with with thumb and pad of index finger with

thumb and index finger) ______utensil resting against side of middle finger)? ______

15. Does the child position scissors correctly in

  1. Is the child able to release an object fingers?______

into a designated area? ______

Miscellaneous

  1. What is the smallest item the child is able

to release (e.g. stuffed animal, block, 1. Is the child able to follow 2-3 step directions?______

cereal)? ______2. Does the child display a high level of activity?______

3. Is the child able to maintain the attention needed

  1. Is the child able to bring his or her hands to complete a task?______

together to play with an object or to clap? ______

  1. Is the child able to bring his or her hands

together to play with an object or to clap? ______

  1. Visual-Motor

YesNo YesNo

  1. Does the child visually attend to objects 4. When coloring:

during interaction(e.g. cutting, prewriting, (please include work sample)

tasks)?______- the child makes random marks on the paper______

-the child attempts to remain in defined area______

  1. Can the child complete a 3-shape form board?______-the child fills approximately ______

amount of the shape/area______

  1. Is the child able to copy the shapes listed below 5. Has printing student’s name been introduced

as commensurate with the child’s age? in the classroom?______

6. Can the child independently trace the letters

ShapeChronological Age in his or her first name?______

7. Can the child independently print his or her

Vertical Line2-10______name when given a model?______

Horizontal Line3-0______8. Can the child independently print his or her name

Circle3-0______without a model?______

Cross4-1______9. Can the child snip paper with scissors?______

Right diagonal line(/)4-4______10. Can the child cut a piece of 8 ½ x 11” paper in half?______

Square4-6______11. Can the child cut on a straight line?______

Left diagonal line(\)4-7______12. Can the child cut out a circle?______

X4-11______13. Can the child cut out a square?______

Triangle5-3______

  1. Self-Care/Adaptive Behavior

YesNoYesNo

  1. Is the child able to self-feed a variety of 9. Is the child independent with toileting? If no,

sizes of finger foods?______what steps can the child complete?

  1. Is the child able to use a spoon to self – feed?______
  2. Can the child pour liquid from a pitcher without spilling?______10. Is the child able to put on and take off a coat?
  3. Is the child able to drink from a regular cup without What method is used for putting the coat on

spilling?______(e.g. traditional method or flip over method)______

  1. Is the child able to place a cup on the table after 11. Is the child able to thread the zipper on a jacket

drinking?______and pull the zipper up and down?______

  1. Is the child able to suck from a straw?______12. Is the child able to put on and take off and open
  2. Is the child able to wash his or her hands? and close a book bag?______

If no, what steps can the child complete? 13. Is the child able to hang up a coat and book bag

______on a hook?______

  1. Can the child put shoes on the correct feet?______
  1. Gross Motor

YesNoYesNo

  1. Is the child able to sit and stand independently 9. Is the child able to pedal a tricycle?______

and unsupported?______10. Can the child get in and out of a small chair?______

  1. Can the child stand on one foot?______11. Can the child push a chair toward and from
  2. Can the child jump up, clearing both feet off the ground?______the table?______
  3. Can the child hop on one foot?______12. Can the child get up from and down onto the floor?______
  4. Describe how the child walks up and down the stairs: 13. Can the child manage self on different terrains

______(e.g. grass, gravel, carpet, going up a hill)______

  1. Is the child able to keep up with peers when (please check) 14. Can the child navigate around and over objects

-Walking down the hall in line______on the floor?______

-Walking up and down stairs______15. Can the child maintain balance when challenged?______

  1. Is the child able to run?______16. Does the child trip or fall easily?______
  2. Is the child able to get on and off a riding toy?______17. Can the child access playground equipment

that is appropriate for his or her size?______

  1. Sensory-Motor

TactileYesNoProprioceptiveYesNo

  1. Can the child tolerate others in his or her personal 8. Is the child clumsy or awkward?______

space (e.g. during circle time, in line, free play)?______9. Does the child display self-abusive or self-

  1. Can the child tolerate a variety of textures on his or stimulatory behaviors (e.g. hitting self,______

her hands (e.g. glue, finger paint, shaving cream, sand)?______head banging)? Describe______

  1. Does the child appear irritated by certain clothing ______

textures (e.g. does the child itch or push up his or her ______

sleeves)?______10. Does the child bump into objects?______

  1. Does the child resist having his or her face or hands 11. Is the child a messy eater?______

washed?______

  1. Does the child have specific and/or limited food Auditory

preference?______12. Does the child appear sensitive to sounds in the

classroom (e.g. loud toys, other children talking,

Vestibular school bell, fire alarms)?______

13. What does the child do to demonstrate that he/she

  1. Does the child resist utilizing playground equipment? Is sensitive to sounds (e.g. cover ears)? Describe

What type? ______

  1. Does the child appear fearful or cautious with movement

(e.g. on steps, when climbing or walking)?______