Ape Referral And Observation Checklist - Pe Central

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University of Virginia
Observation and Referral Form
Child’s Name: __________________________
Evaluator:______________
School:
__________________________
Date:
______________
Use this form when first observing a child with a disability who has been referred for adapted physical education. Rate
each item bases on how the child compares to other children in his/her physical education class.
Needs
Significantly
Not
Physical Fitness
Adequate
Improvement
Inadequate
Observed
Performs activities that require upper body
strength (e.g., pushups, throwing, chest pass)
Performs activities that require lower body
strength (e.g., running, hopping, kicking)
Performs activities that require flexibility
(e.g., stretching, bending, tumbling)
Performs activities that require endurance
(e.g., mile run, games that involve endurance)
Body composition (e.g., child’s weight and
general appearance)
Needs
Significantly
Not
Gross Motor Skills
Adequate
Improvement
Inadequate
Observed
Performs non-locomotor skills (e.g., twisting,
turning, balance, bending)
Moving safely around environment (e.g.,
dodging, space awareness; directions)
Uses physical education equipment (e.g., balls,
bats, scooters)
Performs locomotor skills (e.g., running,
jumping, galloping, hopping, skipping)
Performs manipulative skills (e.g., throwing,
catching, kicking, striking)
Dance skills (e.g., rhythm, patterns, creative)
Plays low organized games (e.g., relays, tag,
teacher-made games)
Sports skills (e.g., throwing in softball,
kicking in soccer, volleyball serve, hitting a
tennis ball
Plays organized sports (e.g., basketball,
soccer)

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