MMSD Reference Guide for Consideration of OT and PT Evaluation (Grades 6-12)

Name______Student #______Date ______ Page 1

Activity (Circle the activities of concern) / Environment(For activities indicated, circle the environment) / Describe the difficulties the child is having that interfere with his/her ability to receive educational benefit / Discipline to Consider
OT / PT
Demonstrating safe behavior / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x / x
Maintaining or changing positions / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Maintaining cleanliness or hygiene / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Using bathroom / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x / x
Eating or drinking / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Traveling / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Ascending or
Descending Stairs / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Managing clothing / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x / x
Using tools, materials or toys / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Activity (Circle the activities of concern) / Environment(For activities indicated, circle the environment) / Describe the difficulties the child is having that interfere with his/her ability to receive educational benefit / Discipline to Consider
OT / PT
Storing materials, setup, cleanup / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Beginning or completing tasks / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x / x
Recording information / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Moving in play or leisure activities / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x / x
Communicating / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Interacting in a positive way / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x / x
Regulating own behavior / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Following rules and adult direction / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x
Understanding or remembering / general classroom, large group, small group, lunchroom, playground, art room, computer room, hallway, bathroom, physical education area, vocational setting / x