Occupational Therapy
TEACHER CHECKLIST OF SCHOOL FUNCTION
Students Nae __________________ !ate __________ !"O"#" _________
Teachers Nae __________________ School _____ Re$ion ____ Roo _____
This chec%list identi&ies areas o& concern 'hich ay inter&ere 'ith participation ( learnin$ in school" )lease
chec% the stateents that apply to your student ( return to*
Nae ++++++++++++++++++ Title +++++++++++++++++++ School Site , Roo - +++++++++++
Learnin$ ( #[Link] Sensory
___ !istracti/le0 short attention span ___ Fear&ul o& /ein$ o&& the $round
___ Restless0 hyperacti.e ___ Fear&ul o& [Link] [Link]
___ Slo' 'or%er ___ [Link] [Link] that challen$e /alance
___ !isor$ani1ed0 essy des% ___ !oesnt li%e play$round e2uipent
___ !oesnt coplete assi$nents ___ Cant see to stop [Link]$
___ !i&&iculty cooperatin$ ___ 3ithdra's &ro touch
___ Sees di&&erent0 hard to descri/e 'hy ___ Tends to 'ear only certain types o& clothin$
+++ Cant &ollo' directions or class routines ___ Touches [Link]$0 trou/le %eepin$ hands to sel&
___ !oesnt li%e to ha.e routine chan$ed ___ [Link] /ein$ close to others0 doesnt li%e hu$s
___ Is easily &rustrated ___ Appears [Link] sensiti.e to loud noises
___ Can not $et alon$ 'ith others0 plays alone ___ !istracted /y sounds0 hears sounds others dont
___ Ipulsi.e0 accident prone ___ !i&&iculty listenin$0 coprehendin$ .er/al in&o"
___ Easier to handle in sall $roup situations ___ !oesnt a%e eye contact
+++ Tendency to out/ursts or tantrus +++ !i&&iculty screenin$ out .isual distractions
___ Has trou/le a%in$ needs %no'n appropriately ___ )ic%y eater0 sensiti.e to sells
___ Hard to understand 'hen spea%in$ ___ !i&&iculty stayin$ alert in class
)osture , [Link] Hand
___ Sees 'ea%0 has lo' endurance ___ !oes not see to ha.e a doinant hand
___ )oor des% posture0 slups0 head close to 'or% ___ !i&&iculty usin$ classroo tools0 scissors0 ruler
___ !i&&iculty 'ith stairs0 5upin$0 runnin$ ___ !i&&iculty 'ith dra'in$0 colorin$0 tracin$0 cuttin$
___ Clusy0 a'%'ard0 /ups into others or o/5ects ___ [Link] &ine otor [Link]
___ !oesnt sit in chair correctly ___ )er&ors these [Link] 2uic%ly0 usually sloppy
___ Tendency to con&use ri$ht ( le&t sides o& /ody ___ )oor pencil $rasp0 drops pencil &re2uently
___ Reluctant to participate in physical [Link] ___ Ti$ht pencil $rasp0 &ati$ues 2uic%ly 'hen 'ritin$
___ )re&ers ta/le [Link] ___ !oesnt 'rite le$i/ly0 cant %eep pace in class
___ Has di&&iculty learnin$ ne' otor tas%s ___ !i&&iculty coordinatin$ /oth hands
6ision , 6isual )erception Li&e S%ills
___ !i&&iculty copyin$ &ro /lac%/oard ___ Needs help 'ith dressin$0 eatin$0 /athroo
___ Trou/le discriinatin$ shapes0 letters0 -s ___ Has poor hy$iene ( $rooin$0 essy eater
___ Has letter or nu/er [Link] ___ Sees to need ore assistance than other students
___ !i&&iculty 'ith pu11les0 copyin$ desi$ns
___ !i&&iculty %eepin$ place 'hile readin$
Acadeic !i&&iculties
___ 4ath ___ Readin$ ___ E7pressi.e 'ritin$ ___ [Link] ___ Other _____________________
[Link] o& Concern
)lease indicate your [Link] o& concern a/out the a/o.e di&&iculties ( add any coents /elo'" Than% you"
___ 4ildly concerned ___ 4oderately concerned ___ E7treely concerned
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