Ot/pt Teacher Checklist
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1South Bend Community School Corporation
Special Education Services
OT/PT TEACHER CHECKLIST
Student:
Date:
Date of birth:
School:
Teacher filling out this form:
EDUCATION-RELATED GROSS MOTOR
YES/NO
COMMENTS
SKILLS
Walks independently to all school destinations
Participates in physical education
Plays on playground equipment
Enters and exits bus/van independently
Physically able to sit appropriately in various
settings
Other gross motor concerns
EDUCATION-RELATED FINE MOTOR
YES/NO
COMMENTS
SKILLS
Uses pencils or crayons age-appropriately
Cuts with scissors
Manipulates school materials (age appropriately)
Other fine motor concerns
Independent bathroom skills
Independent cafeteria skills
Independent with all clothing
Manages backpack, locker and cubby
Other
Answer Yes or No to each question about the student. If “No” is schedked, it is likely
that a therapy screen is appropriate. For gross motor concerns, consult the Physical
Therapist. For fine motor, consult the Occupational Therapist.
For Therapist Use Only
Interventions given to teacher
Yes
No
Date:
(circle one)
Comments:
Follow-Up Date:
Results:
Screen warranted
Yes
No Therapist’s Signature
(circle one)
Rev10/2014
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