FULTON COUNTY SCHOOLSServices for Exceptional Children

Jo Wells Center54 Parkway Drive

Hapeville, Georgia 30334404-763-5600

Collaborative Evaluation for Occupational Therapy

NAME: ADDRESS: DOB: SCHOOL: AGE: GRADE: Type of Evaluation: Initial Re-EvaluationTEACHER/DIAGNOSTICIAN (SECTION I) OCCUPATIONAL THERAPIST (SECTIONS II, III): SPECIAL EDUCATION ELIGIBILITY: 504 PLAN YES NO

PART I

REQUEST FOR ASSISTANCE

MEDICAL HISTORY:

Uncomplicated pregnancy Premature delivery Cesarean delivery Breech birth Developmental milestones on time Developmental milestones delayed Healthy child Diagnosed with Medical Precautions/Allergies List Current Medications

PHYSICAL DEVELOPMENT AND ACCESS:

Hearing Normal Hearing Loss Wears hearing aides Cochlear implant Classroom FM SystemVision Normal Wears glasses/contacts Far sighted Nearsighted

EDUCATIONAL HISTORY: Small group intervention Team Taught Combination Team Taught and Small Group Self-contained class No formal schooling/group settings Babies Can’t Wait: OT PT Speech

THERAPY HISTORY: Currently receiving occupational therapy in school setting Currently receiving private therapy Previously received School Therapy Private Therapy

PRESENTING PROBLEM(S)/AREAS OF OCCUPATIONAL PERFORMANCE: SELF HELP SKILLS: The student’s ability to manage personal needs within the educational environment. CLASSROOM PERFORMANCE & PARTICIPATION: The student’s abilities in the areas of attention, organization,

peer interaction, social-emotional functioning, activity level, etc. as they relate to functioning in the classroom. FINE MOTOR SKILLS: The student’s ability to manipulate and manage materials within the educational environment PRE-WRITING/HANDWRITING SKILLS: The student’s demonstration of early writing readiness, including visual

motor and visual perceptual aspects of pre-writing/handwriting. PHYSICAL ACCESS & PARTICIPATION: The student’s physical status and ability to perform basic motor actions as

needed to function in and move throughout the educational environment. Other: describe:

CONTEXT/SETTING in which presenting problem occurs: General Education ClassroomSpecial Education ClassroomHall/stairwaysCafeteria BathroomPlayground/recess CBI LocationOther

DESCRIPTION OF PROBLEM(S):

DESCRIPTION OF CLASSROOM STRATEGIES/ INTERVENTIONS:

RESULTS OF DATA COLLECTION FROM RTI STRATEGIES

SPECIFIC IEP GOALS / IEP OBJECTIVES NOT PROGRESSING:

Teacher: ___________________________ Date:_______________________________

PART 2STRUCTURED OBSERVATION/INFORMAL ASSESSMENT

(Complete only those sections related to Presenting Problem(s)/Areas of Concern)

Student Date

ASSESSMENT PROCEDURES :

Observation Parent Report Teacher Report Checklists Work samples

SELF HELP

Dressing Skills: Educational Impact: Yes No

Jacket: Takes off Independently Physical Assist Unable

Puts on Independently Physical Assist Unable

Backpack: Takes off Independently Physical Assist Unable

Puts on Independently Physical Assist Unable

Shoes: Takes off Independently Physical Assist Unable

Puts on Independently Physical Assist Unable

Zipper: Takes off Independently Physical Assist Unable

Puts on Independently Physical Assist Unable

PE Clothes: Takes off Independently Physical Assist Unable

Puts on Independently Physical Assist Unable

Comments:

Bathroom Skills: Educational Impact: Yes No

Toileting age appropriate

Toilet Trained Yes No In process of being toilet trained Trip Trained

Able to Access Bathroom Commode Toilet Paper Sink Soap Paper Towels

Requires Adaptive Equipment Yes Describe

Clothing Independent Physical Assist Unable

Difficulty with Bathroom Noises: Yes No

Comments:

Mealtime Skills: Educational Impact: Yes No

Independent with all mealtime tasks

Eats with Spoon Independent Assist

Fork Independent Assist

Fingers Independent Assist

Drinks from Cup Sippie cup Milk Carton Adaptive cup

Uses Straw Yes No

Tray Independent Tilts tray causing spills Unable

Containers Independent Physical Assist Unable

Food Pockets Overstuffs loss of food from mouth

Wipe Face Independent Physical Assist

Comments:

Managing Materials: Educational Impact: Yes No

Manages personal belongings Yes No

Handles materials roughly causing breakage/spills Yes No

Classroom Tools:

Backpack: Hang up Independently Physical Assist Unable

Retrieve items Independently Physical Assist Unable

Manages Notebook Independently Physical Assist Unable

Supplies(pencil eraser) Independent Physical Assist Unable

Locker Independent Physical Assist Unable

Comments:

CLASSROOM PERFORMANCE AND PARTICIPATION

Attention/Level Distractibility: Educational Impact: Yes No

Attends and participates in: all activities group activities 1:1 activities

Visual attention: good inconsistent good but does not actively participate

Easily distracted by: auditory visual stimulation

COMMENTS:

Following Directions: Educational Impact: Yes No

Follows class rules and routines Yes No

Follows directions across all settings Yes No

Follows: 1 step directions 2 step directions 3 step directions directions in a group

Performs directions in proper sequence Yes No

Comments:

Transitions: Educational Impact: Yes No

Difficulty with: new environments changes in routine transitions between activities

Comments:

Personal Space: Educational Impact: Yes No

Invades personal space of peers Touches peers/materials without permission

Not able to stay in designated areas Bumps into furniture/peers objects

Difficulty walking in line in hallway Leans on people/surfaces

Comments:

Self Regulation/Modulation: Educational Impact: Yes No

Self-regulation Good in all environments No, Describe

Handles frustration without outburst or aggression verbal outbursts physical outbursts

Works with peers Cooperatively Unable to work cooperatively with peers

Difficulty with self-regulation in: Large groups small groups 1:1

Distressed by: Accidental touch Imposed or unexpected movement Loud Noises

Demonstrates self-stimulating behaviors Yes No Describe Click here to enter text.

Affect or arousal Low High Adequate

Persistent fidgeting Yes No

Comments:

FINE MOTOR SKILL

Hand Dominance: Right Left Switches Hands

Upper Extremity ROM: Within Functional Limits No, Explain

Upper Extremity Tone: Within Functional Limits No, Explain

Reach: Adequate Overshoots Undershoots

Grasp and Release Patterns: Educational Impact: Yes No

Grasp: Raking pincer grasp 3 jaw-chuck Lateral

Release Raking for small objects/finger foods Difficulty with gradation of release

Writing utensils: Closed webspace Thumb wrap Pronated palmer grasp

Tripod grasp Fisted Quadrupod grasp

Comments:

Manipulation Skills: Educational Impact: Yes No

Good finger isolation Yes No

Uses both hands efficiently for bilateral tasks Yes No

Able to translate object from palm to fingertips Yes No

Drops objects during manipulation Yes No

Stabilizes on surface or body Yes No

Comments:

Scissor Skills: Educational Impact: Yes No

Scissors: Regular Adaptive Scissors. Describe

Age appropriate cutting skills Yes No

Grasp Able to sustain grasp on scissors Pronated grasp Assist to aintain grasp

Cutting Snips paper 1-2 times Makes consecutive cuts Choppy cutting pattern

Unable to cut forward Unable to cut simple shapes within ¼ inch of line

Difficulty rotating paper Unable to open scissors independently

Comments:

PRE-WRITING/HANDWRITING

General Visual Classroom Observations: Educational Impact: Yes No

Scanning L>R(e.g. calendar/counting) Yes No

Scanning vertically (e.g. board>desk) ) Yes No

Scanning environment Yes No

Able to trace Yes No

Able to copy Yes No

Observations Squints Tends to look with peripheral vision Covers eyes/complains about light

Comments:

Physical Observations/Tracking: Educational Impact: Yes No

Track moving target Yes No

Track in all planes with smooth pursuits Yes No

Head posture: Midline on shoulders Tilts to left Head tilts to right

Disassociates eyes from head movement Yes o

Eye turns right left in out

Comments:

Coloring: Educational Impact: Yes No

Age appropriate coloring Yes No

Visual attention adequate not adequate

Pressure adequate excessive light

COMMENTS:

Prewriting: Educational Impact: Yes No

Spontaneously scribbles Yes No

Draws simple pictures Yes No

Imitates: _ l O X + triangle square

Copies: _ l O X + triangle square

Comments:

Handwriting: Educational Impact: Yes No

Letters size Appropriate Large Small

Letter formation Appropriate Illegible Bottom to Top

Reversals Yes No

Adequate space between letters Yes No

Adequate space between words Yes No

Orients left to right Yes No

Pressure Adequate Excessive Light

Erasing Adequate Excessive Light

Speed Adequate Rushes to complete Takes more time to complete

Baseline adherence Adequate Letters float Letters stray below the line

Comments:

Keyboarding/Technology Use: Educational Impact: Yes No

Use of Mouse age/grade appropriate: Yes No

Keyboarding Skill age/grade appropriate: Yes No

Uses network word prediction software: Yes No

Uses network software with auditory feedback: Yes No

Comments:

PHYSICAL ACCESS AND PARTICIPATION

Sitting Posture: Educational Impact: Yes No

Sits erect, feet flat Yes No

Rounded Back Yes No

Legs Wrapped around Chair Yes No

Sits on Legs Yes No

Able to Move in and Out of Positions at Desk Yes No

Comments:

Upper Extremity Functional Strength: Educational Impact: Yes No

Within Functional Limits

Decreased on: Left Right Both

Comments:

Endurance: Educational Impact: Yes No

Fatigues easily with sustained fine motor activity Yes No

Fatigues easily with sustained gross motor activity Yes No

Postural fatigue with prolonged sitting Yes No

Comments:

Playground/Recess: Educational Impact: Yes No

Participates appropriately Yes No

Safety awareness on playground Yes No

Enjoys movement in all planes Yes No

Excessive force during movement games Yes No

Fears playground equipment Yes No

Comments:

SUMMARY AND RECOMMENDATIONS

The results of this observation are considered to be an accurate reflection of current school functioning: Yes No for the following reasons: Implement the following recommendations for weeks.

Occupational Therapist:______________________ Date:_____________________

FOLLOW UP DATE: Click here to enter text.

RESULTS OF CLASSROOM INTERVENTIONS:

Classroom interventions effective. Continue strategies.Classroom interventions not effective. Consider formal assessment.

Occupational Therapist: Teacher:

Date:

PART 3

STANDARDIZED ASSESSMENTS

Name Date

Peabody Developmental Motor Scales (PDMS-2) provides information regarding fine motor skills. The areas measured indicate a child’s ability to use his or her hands as well as visual perceptual skills needed to perform complex eye-hand coordination tasks such as reaching/grasping objects, copying designs, and controlled use of the fingers of both hands for manipulation of objects within the child’s environment.

Two subtests from this test were used:

Grasping (Gr): This subtest measures a child’s ability to use his or her hands. It begins with the ability to hold an object with one hand and progresses up to actions involving the controlled use of the fingers of both hands to button and unbutton garments.

Visual –Motor Integration (Vi): This subtest measures a child’s ability to use his or her visual perceptual skills to perform complex eye-hand coordination tasks such as reaching and grasping for an object, building with blocks, and copying designs.

Subtest Raw Score Standard Score (avg 85-115)

Percentile (avg 16-84)

Grasping

Visual Motor Integration

Fine Motor Quotient (FMQ): This quotient measures a child’s ability to use his or her hands and arms to grasp objects, stack blocks, draw figures, and manipulate objects. High scores on this composite are made by children with well-developed fine motor abilities. These children would have above average skills picking up small objects, drawing figures, and stringing beads. They are likely to be described as good with their hands; low scores are made by children who have weak grasping and visual-motor skills. They have difficulty in learning to pick up objects, draw designs, and use hand tools. A fine motor deficit can be mild; the child’s skills may be described as immature. Some children may have problems severe enough to need specially designed utensils to feed themselves.

A Fine Motor Quotient (FMQ) of ___ represents ______ performance. The FMQ is a numeric representation of the child’s overall performance on the Grasping and Visual-Motor Integration subtests.

Quotient Sum of Standard. Scores

Quotient Score

(35 to 165)

Percentile Rank

Fine Motor (FMQ)

Interpretation of test results:

The Wide Range Assessment of Visual Motor Abilities (WRAVMA ) assesses three areas using three subtests. These three areas have been selected because of their relevance to school-related activities. The drawing (visual-motor) test has children copying from designs which are developmentally arranged in order of increasing difficulty. Starting at an age appropriate item, the child copies a standard design and proceeds until three consecutive items are failed. The Matching (Visual-Spatial) test provides a measure of spatial skill by presenting visual spatial tasks developmentally arranged in order of increasing difficulty. The child continues until he/she makes six errors within a series of eight consecutive items. The pegboard (fine motor) test has the child insert as many pegs as possible within 90 seconds using a nearly square pegboard. The pegboard is waffled to add to its fine motor demands.

Scores are listed below:

Raw Score Standard Score (avg 85-115)

Percentile Score (avg 16-84)

Drawing test (visual-motor)

Matching test (visual-spatial)

Pegboard test (fine motor)

VMA Composite

Interpretation of test results:

Bruininks-Oseretsky Test of Motor Proficiency

The Bruininks-Oseretsky Test of Motor Proficiency was given to assess fine motor skills in various areas of performance. The Bruininks tests different aspects of fine-motor control and functioning. Fine motor control, dexterity, upper-limb coordination and visual-motor control are tested to determine if children have the foundation skills and abilities to perform everyday fine-motor tasks.

Scaled Score Sum of Scaled Scores Standard Score

Mean=15, SD=5 Mean=50, SD=10

Fine Motor Precision Fine Manual Control

Fine Motor Integration

Manual Dexterity Manual Coordination

Upper-Limb Coordination

Bilateral Coordination

Interpretation of test results:

The Test of Visual Perceptual Skills, 3rd Edition

The TVPS-3 assesses an individual’s visual perceptual abilities without requiring motor involvement when making a response. The test utilizes black and white line drawings as stimuli for the perceptual tasks. The items are presented in a multiple-choice format. Visual perceptual subtest scores are very highly inter-correlated because of those high inter-correlations, it should be recognized that any one subtest may not measure discretely just one perceptual ability.

Subtests Subtest Scores

Average range 7 to 13

Index Scores

Average range 85 to 115

Raw Score (avg. range 7-13)

Scaled Score

Percentile Rank (avg. range 16-84)

Overall Basic Processes

Sequencing Complex Processes

Visual Discrimination

Visual Memory

Spatial Relations

Form Constancy

Sequential Memory

Figure Ground

Visual Closure

Sum of Scaled

Scores

Standard Scores

Interpretation of test results:

The Test of Visual-Motor Skills, Revised, and (TVMS) was given to assess visual motor skills. These skills are needed to support handwriting and other academic tasks. The TVMS requires children to copy increasingly complex geometric designs. Students are not allowed to erase while copying designs. The mean Standard score for the TVMS is 100 and the mean Scaled score is 10.TVMS scores:Raw Score Standard Score Scaled Score

Interpretation of test results:

The Beery-Buktenica Developmental Test of Visual Motor Integration, 5 th Edition (VMI)

The VMI measures a student’s ability to reproduce shapes of increasing complexity following a developmental sequence. It is designed to assess the extent a student can integrate his visual and motor abilities (visual-motor integration). The visual and motor subtests respectively measure one’s ability to discriminate visual details and to draw lines in specific areas

Standard Score (avg 85-115)

Scaled Score (avg 7-13)

Percentile (avg 16-84)

VMI

Visual

Motor

Interpretation of test results:

SENSORY MOTOR SKILLS

The Sensory Profile School Companion was administered as part of a comprehensive assessment to determine whether aspects of sensory processing might be contributing to a student’s challenges in the classroom or school environment.

The Sensory Profile School Companion is a measure of students’ responses to sensory events in the classroom. The teacher completes the Sensory Profile School Companion by assessing the frequency of a student's responses to environmental sensations, body sensations and his or her classroom behaviors as described in 62 items. We know from research that the Sensory Profile School Companion can help identify a student’s sensory processing patterns; the results can then be used to consider how these patterns might be contributing to or creating barriers to performance in the classroom.

His\her classroom teacher completed the School Companion.

The Sensory Profile looks at 2 primary factors, neurological thresholds and self-regulation strategies.

Neurological thresholds are the way the nervous system responds to sensory input. Self regulation strategies are the ways that people manage the input that is available to them. Many things can

affect responsiveness or the way that a person’s self-regulation strategies affect daily life. Demands of a person’s environments, an activity or a person’s self-regulation strategies can affect responsiveness.

o Hypo-responsive (or under responsive) is when a system is responding too little.o Hyper-responsive (or over responsive) is when a nervous system is responding too much.

Everyone has times when we are hyper-responsive or hypo-responsive; it is only when a response interferes with everyday life consistently that it needs to be addressed.

There are 4 basic patterns of responding to sensory events in everyday life.

Sensation Seeking is the combination of high neurological thresholds and an active self regulation strategy. Low registration is the combination of high neurological thresholds and a passive self regulation strategy. Sensation Avoiding is the combination of low neurological thresholds and an active self regulation strategy Sensory Sensitivity is the combination of low neurological thresholds and a passive self regulation strategy

Sensory Profile School Companion Scores:

Less Than Others Similar to Others

More Than Others

Much Less Than Others

Less Than Others

More Than Others

Much More Than Others

Section Raw Score Total

Definite Difference

Proable Difference

Typical Performance

Probable Difference

Definite Difference

1. Auditory: /50 50 49----------38 37-----X-----31 30----------10

2. Visual: /55 55----------53 52----------39 38----------31 30----------11

3. Movement: /70

70----------56 55------X----48 47----------14

4. Touch: /60 60----------51 50----------45 44----------12

5. Behavior: /75

75 74----------58 57----------49 48----------15

Less Than Others Similar to Others

More Than Others

Much Less Than Others

Less Than Others

More Than Others

Much More Than Others

Quadrant Raw Score Total

Definite Difference

Probable Difference

Typical Performance

Probable Difference

Definite Difference

1. Registration: /85

85 84----------64 63----------53 52----------17

2. Seeking: /60 60----------43 42----------34 33----------12

3. Sensitivity: /80

80----------79 78----------60 59----------51 50----------16

4. Avoiding: /85 85-----------70 69----------61 60----------17

Less Than Others Similar to Others

More Than Others

Much Less Than Others

Less Than Others

More Than Others

Much More Than Others

School Factor Raw Score

Definite Difference

Proable Difference

Typical Performance

Probable Difference

Definite Difference

1. School Factor 1: /105

105----------79 78----------64 63----------21

2. School Factor 2: /65

65----------64 63----------44 43----------34 33----------13

3. School Factor 3: /85

85----------70 69----------61 60----------17

4. School Factor 4: /55

55-----------42 41----------35 34----------11

The student scored in the Definite Difference range for:

The student scored in the Probable Difference/More Than Others range for:

The student scored in the Definite Difference range for:

School Factor 1:  External supports to be prepared for learning. (Seeking and Registration) Typically “Definite Difference” scores in this area correlate to a student who requires extra sensory input to reach the higher threshold of registration in order to be prepared for learning.  These students generally require the attention of the teacher or environmental things to get their sensory needs met in order to reach their higher threshold of sensory input needed for active learning.

School Factor 2:  Awareness and attention within the learning environment.  (Seeking and Sensitivity)With “Definite Difference” scores in this area, students are being pulled away from learning activities because of attention to other stimuli in the environment.  Students that fall into this category often need a learning environment with less distraction or stimulation so they can focus on their work.

School Factor 3:  Tolerance for sensory input. (Avoiding and Sensitivity) A student who has a “Definite Difference“, a score in this area will avoid a stimuli, otherwise they will become over reactive and frustrated in a situation.  These students may become overloaded quickly in typical learning environments which, can interfere with their ability to get directions, complete class work, or cooperate with other students in large groups.  These children can appear less tolerant, over reactive, and picky compared to their peers.

School Factor 4:  The student’s level of availability for learning.  (Avoiding and Registration)  These students are missing opportunities to participate and often look uninterested, making them look like they need to “check back into” classroom activities.  With these students they need the “just right” level of sensory stimuli to keep them engaged, but not too much to over stimulate them.

MODULATION: Sensory modulation is the ability to modulate or self-regulate one’s mental arousal level. Students with good sensory modulation are calm and focused most of the time, and therefore are ready to do their classwork. Children who are easily over-stimulated or who tend to be under-active may have difficulty with modulation, and therefore have trouble concentrating on their work.

DISCRIMINATION:

The following sensory processing skills appear to be adequate or inadequate for classroom work, based on observations:

The Sensory Processing Measure was administered as a way of obtaining a complete picture of the student’s sensory functioning across different environments including home, as well as the main classroom. It is a standardized norm referenced tool with scores for five sensory systems (vestibular, proprioceptive, tactile, visual, and auditory) as well as praxis (motor planning / ideation) and social participation. Scores for each scale fall into one of three interpretive ranges: Typical (40-59T), Some Problems (60-69T), or Definite Dysfunction (70-80T).

Scores for Main Classroom Form Interpretive Range Typical Performance Some Difficulties Definite Dysfunction

Raw Score T-Score Raw

Score T-Score Raw Score T-Score

Social ParticipationVisionHearingTouchBody AwarenessBalance and MotionPlanning and IdeasTotal Sensory SystemsInterpretation

SOCIAL: VISION: HEARING: TOUCH: BODY AWARENESS: PLANNING AND IDEAS:

The Sensory Processing Measure is an integrated system of rating scales that enables assessment of sensory processing issues, praxis and social participation in elementary school-aged children. It consists of three forms: the Home Form, The Main Classroom Form and the School Environments Form. The measure provides a perspective on a child’s sensory functioning in home, school and community environments. The Main Classroom Forms was completed by……………. The Home Form was completed by …………. The School Environment Forms were not included with this evaluation. The results are as follows:

Main Classroom Form

Social Participation

Visual Hearing Touch Body Awareness

Balance and Motion

Planning and Ideas

Total

Raw Score

T-Score

Interpretive Range

Typical (40T-59T)

Some Problems (60T-69T)

Definite Dysfunction (70T-80T)

Home Form

Social Participation

Visual Hearing Touch Body Awareness

Balance and Motion

Planning and Ideas

Total

Raw Score

T-Score

Interpretive Range

Typical (40T-59T)

Some Problems (60T069T)

Definite Dysfunction (70T-80T)

The Print Tool was used to assess handwriting skills. The Print Tool is designed to assess students over six years old who are having handwriting difficulties. It evaluates uppercase letters, lowercase letters and numbers for:

1. Memory: remembering and writing dictated letters 2. Orientation: facing letters in the correct direction (non-reversal) 3. Placement: putting letters correctly on baseline of the paper 4. Size: How big or small letters are written 5. Start: where each letter begins 6. Sequence: order and stroke direction of the letter parts7. Control: neatness and proportion of the letter parts8. Spacing: the amount of space between letters in words and words in sentences

The Print Tool provides an appropriate remediation plan to increase handwriting skills.

Handwriting Results are as follows:

Memory Orientation

Placement Size Start Sequence

Control Letter Spacing

Word Spacing

UC Letters

LC

Letters

Numbers

The Student’s overall score is ____% Accuracy for handwriting skills. The areas that are in bold are in need of remediation.

Suggested Targets for children 6 years old are as follows:

Memory Orientation

Placement Size Start Sequence Control Letter Spacing

Word Spacing

UC Letters

85% 85% 80% 70% 85% 80% 75% N/A N/A

LC

Letters

85% 85% 80% 70% 85% 80% 75% 80% 80%

Numbers 85% 85% 80% 70% 85% 80% 75% N/A N/A

Suggested Targets for children 8 years or Older are as follows:

Memory Orientation Placement Size Start Sequence

Control Letter Spacing

Word Spacing

UC Letters

100% 100% 95% 85% 95% 95% 95% N/A N/A

LC

Letters

100% 100% 95% 85% 95% 95% 95% 100% 100%

Numbers

100% 100% 95% 85% 95% 95% 95% N/A N/A

Interpretation of test results:

Test of Handwriting Skills-Revised

The Test of Handwriting skills is an untimed assessment of manuscript and/or cursive handwriting. The test assesses writing spontaneously from memory, writing from dictation, copying letters, copying words and copying sentences.

Subtest Raw Score Scaled Score Percentile (avg. 7-13) (avg 16-84)

Airplane(UC Alphabetical order)

Bus(LC Alphabetical order)

Butterfly (UC Random order)

Frog(LC Random order)

Bicycle(Numbers Random order)

Tree(Copy 12 UC letters)

Horse(Copy 10 LC letters)

Truck (Copy 6 words)

Book(Copy 2 sentences)

Lion(Dictated Sentences)

Sum Scaled Scores

Standard Score (avg. 100 ± 15)

Overall Percentile Rank

Interpretation of test results:

School Functional Assessment (SFA)

School Functional Assessment (SFA) is used to measure a student’s performance of functional task that support his or her participation in the academic and social aspects for grades K-6. It is designed to facilitate collaborative program planning for students with a variety of disabling conditions.

The SFA is comprised of three parts:

Part 1 Participation which examines the student’s participation in six major school activity settings: regular or special education classroom, playground or recess, transportation to and from school, bathroom and toileting, transitions to and from class, and mealtime or snack time.

Part 2 Task Support which examines the support currently provided to the student when he or she performs school-related functional task that are required to participate in an educational program. Two types of task support are examined: assistance and adaptation.

Part 3 Activity Performance which examines the student’s performance of specific school-related functional activities. Each scale includes a comprehensive set of activities that share a common functional demand such as moving around the classroom/ school, using school materials, interacting with others, following school rules, and communicating needs. If a student achieves a criterion score less than 100, the criterion cut-off score will determine whether this score is below the level of his or her typically performing peers.

Interpretation of the SFA

Part 1 Participation: Lower scores indicate that the student participates less than his or her same grade peers while higher scores indicates that the students participates more fully in the school activities settings rated.

Part 2 Task Support: Lower scores indicate that the student needs more frequent, extensive, and individualized help or modification to support task performance in that domain. Higher scores indicate that the amount and type of support the student receives for task performance is more like that offered to same grade peers.

Part 3 Activities Performance: Lower scores indicates that the student is limited in his or her performance of some or all of the activities that form a particular scale, whereas higher scores indicate that the student performance approaches that expected at his or her grade level.

Functional Profile

Reg. Classrm

Special Classrm

Playgrnd/Recess

Transportation

Bathrm/Toileting

Transitions Meals/Snacktime

Setting

Rating

Part I Participation Total Raw

Score

Criterion

Score

Standard

Error

Criterion Cut-

Off Score (K-3)

Criterion Cut-

Off Score (4-6)

Regular Classroom + 5 Settings

Special Education Classroom + 5 Settings

Part II Task Supports

Physical Tasks – Assistance

Physical Tasks - Adaptations

Cognitive/Behavioral Tasks-Assistance

Cognitive/Behavioral Tasks-Adaptations

Optional

Tasks

Up/Down Stairs-Assistance

Up/Down Stairs-Adaptations

Written Work-Assistance

Written Work-Adaptations

Computer and Equipment Use-Assistance

Computer and Equipment Use-Adaptations

Physical

Tasks

Part III Activity Performance

Travel

Maintaining and Changing Positions

Recreational Movement

Manipulation with

Movement

Using Materials

Setup and Cleanup

Eating and Drinking

Hygiene

Clothing Management

Up/Down Stairs

Written Work

Computer and Equipment Use

Cognitive/Behavioral

Tasks

Functional Communication

Memory and Understanding

Following Social Conventions

Compliance w/Adult Directives and School Rules

Task Behavior/Completion

Positive Interaction

Behavior Regulation

Personal Care Awareness

Safety

Interpretation of test results:

Summary:

The members of the student’s Individual Education Program will review the results of this evaluation, along with the Georgia Consideration Tools to make appropriate educational recommendations to address identified needs.

Occupational Therapist: Date: