Staunton City Schools Health Screening Form Page 2
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1
2Height and Weight
(School Nurse in grades K, 3, 7, 10)
Height (in.)________________
Weight (lbs.)_____________________
Signature _______________________________ Title ____________________________ Date ____________
********************************************************************************************
Fine and Gross Motor Skills Evaluation
Place a check next to the skills students are able to perform. To fail the fine and gross motor screening, a child must fail 2 out of 3 gross motor skills AND both fine motor
skills. A child is allowed 2 attempts to pass each skill.
Fine Motor Evaluation – to be completed by classroom teacher
st
nd
rd
Skill
Kindergarten
1
grade
2
grade
3
grade
Visual Motor Skills
Copy a circle and make
Draw a line within a
Draw a line within a curved
Draw a line within a
predominantly circular
curved path with no
path with no more than 2
curved path with no
lines
more than 2 deviations
deviations from the curved line
more than 2 deviations
from the curved line
from the curved line
Upper Extremity Speed
Within 30 seconds
Within 20 seconds
Within 20 seconds
Within 15 seconds
and Dexterity – place 5
pegs in a pegboard using
one hand
Gross Motor Evaluation – to be completed by physical education teacher
st
nd
rd
Skill
Kindergarten
1
grade
2
grade
3
grade
Balance – hold right foot off ground and
5
10 seconds
10 seconds
12 seconds
hold left foot off ground
seconds
Bilateral Coordination – Jump in air
Clap 5
Clap 5 times
Clap 5
Touch both heels
and…
times
times
with both hands 2
out of 3 times
Upper extremity coordination – toss ball
8 ½ inch
8 ½ inch ball
4 to 5 inch
4 to 5 inch ball
in air and catch it 5 times consecutively
ball
ball
Comments:
__________________________________________________________________________________________________________________________________________
Pass/Fail: _____________
********************************************************************************************
Instructions for 60-Day Speech, Language, and Voice Observations
Within 60 days of initial enrollment in a public school, the classroom teacher shall:
Observe the speech, language, and voice of each student in the class.
For the students who exhibited no difficulties, note in block three of the 4x4 form.
For the students who showed problems, refer to the speech/language pathologist.
After consultation with the classroom teacher, the speech pathologist shall (as appropriate):
Observe the child in the natural setting.
Perform additional observations as necessary.
Follow up as indicated by classroom teacher results.
Provide observation results to classroom teacher.
New Student Speech, Language and Voice Observation Instrument
To the classroom teacher: If any of the following behaviors are checked as “observed”, consult the speech and language pathologist.
Student Name:
Observation Date:
Limited English Proficiency: Yes
No
Grade:
Screened By:
Teacher:
Observed Behavior
Check
1.
Child is difficult to understand.
Sounds in error:
2.
Child has a hoarse and/or nasal voice that does not seem related to a cold or allergies.
3.
Child uses grammar inappropriate for age and peer group.
4.
Child has difficulty following directions and/or responding to questions. Difficulty understanding directions
Yes
No
5.
Child has difficulty making wants and needs known.
6.
Child has difficulty using complete sentences.
7.
Child’s vocabulary seems limited for age.
8.
Child has difficulty expressing an idea or event (i.e. what he did over the weekend).
9.
Child avoids talking or appears frustrated when speaking.
10.
Child has difficulty controlling pauses, repetitions, facial or neck movements when speaking (stuttering).
Other communication concerns:
No communication problems were noted.
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