OCCUPATIONAL THERAPY ELEMENTARY SCHOOL CHECKLIST

Student’s Name: ______Grade: ______

Teacher: ______Date of Birth: ______

School: ______Date Completed: ______

Dear Teacher,

Observation of a student’s behavior in the classroom is particularly helpful in determining the need for Occupational Therapy services. The following items are related to the learning process. Please read through the categories and think about how this child performs in the classroom as compared to the other children. Check the appropriate current level of performance below.

Motor Development / Average as
Compared to Peers / Mild Difficulty as Compared to
Peers / Significant
Difficulty as Compared to
Peers
Awkward in running, climbing, skipping, jumping, and kicking
Difficulty with playground or physical education activities
Difficulty following and participating in classroom motor games/songs/activities
Poor posture at desk or when seated on the floor
Easily fatigued during physical activity
Body Awareness/Sensorimotor Skills / Average as Compared to Peers / Mild Difficulty as Compared to Peers / Significant Difficulty as Compared to Peers
Avoids getting hands in paste, sand, and other “messy” materials
Is irritated by clothing of certain textures
Dislikes being touched unexpectedly or sitting close to someone else
Hesitates to climb or play with equipment that moves
Has poor body awareness of self in space, bumps into walls, children, and desks
Invades personal space of others
Has difficulty sitting appropriately during circle or carpet time
Has difficulty determining left from right in games and activities
Has difficulty tolerating loud noises
Seeks out oral input (puts objects or hands in mouth)
Tends to pinch, hit, or bite oneself or others
Seems not to hear or ignores auditory directions
Functional School Tasks/Self-
Care Tasks / Average as Compared to Peers / Mild Difficulty as Compared to Peers / Significant Difficulty as Compared to Peers
Difficulty in cutting, pasting, coloring, etc.
Holds pencil, crayon, scissors awkwardly
Inconsistent hand preference
Works slowly on simple paper-pencil tasks
Illegible handwriting
Constantly shifts position or adjusts paper when writing
Strokes too heavily or too lightly with pencil, crayon, or eraser
Difficulty managing backpack (items in/out or zipper)
Difficulty managing locker/lock
Difficulty utilizing school tools (ruler/stencils, folders, pencil sharpener, paper clips, binder, etc.)
Difficulty using the computer mouse or keyboard
Difficulty with cafeteria tasks (using utensils, opening packages, carrying tray)
Difficulty with organization of school materials, belongings, personal space
Difficulty following and completing morning and afternoon routines
Difficulty with clothing management, including fasteners
Difficulty with personal care awareness (monitoring and maintaining basic appearance, face, nose, hands)
Difficulty with bathroom/grooming routines (managing bathroom stall door and lock, obtaining and using toilet paper, water, soap, paper towels, etc.)
Visual Spatial Skills / Average as Compared to Peers / Mild Difficulty as Compared to Peers / Significant Difficulty as Compared to Peers
Difficulty matching or sorting by color, shape, and size
Omits words, skips lines, loses place while reading or copying
Difficulty in recognizing reversals of numbers and letters (Note: This is common up until the first half of first grade.)
Difficulty with puzzles, mazes, hidden words, crossword puzzles, etc.
Poor spacing/sizing of drawings or letters
Behavior / Average as Compared to Peers / Mild Difficulty as Compared to Peers / Significant Difficulty as Compared to Peers
Distractible- limited ability to screen out irrelevant stimuli
Hyperactive – restless activity, always moving, fidgets
Hypoactive – slow, lethargic, seems to lack interest or motivation
Impulsive, hasty making decisions
Tends to avoid group situations
Difficulty socializing with classroom peers
Self-esteem/general feeling of self-worth
Needs assistance to complete most classroom tasks
Difficulty following social conventions
Difficulty with transitions or changes in school routines
Demonstrates anxiety related to school environment