Rev. 09/15/99
D U R H A M P U B L I I C S C H O O L S
O C C U P A T I I O N A L / / P H Y S I I C A L T H E R A P Y R E F E R R A L
N AME :
SS/S TUDENT ID#:
T EACHER :
C AREGIVER ( S ):
Permission to Evaluate Received
Date of Team Referral
S CHOOL :
G RADE /R OOM #:
A DDRESS :
DOB:
P HONE :
M EDICATIONS :
(Home)
A LLERGIES :
A
SSISTIVE
D
EVICES
U
SED
(e.g., glasses/contacts, hearing aids, other):
(Work)
E
LIGIBILITY
C
ATEGORY
: IEP D
ATE
: 3-Y
R
.
R
E
-E
VAL
.
D
ATE
:
Student receives the following services circled below:
OT PT S&L Resource
Lunch: Recess:
Resource/Related Services:
Specials:
Other:
Read the description of each school-related task. Check whether the student is functional (F) or needs improvement (N) with each task as compared to his/her classroom peers.
S
CHOOL
-R
ELATED
T
ASKS
F N
T
RAVEL
: moving on all different types of indoor and outdoor surfaces; moving around obstacles, through congested or narrow spaces, or in a line; moving all distances required in school, including evacuating the building as necessary; moving up and down stairs safely.
M AINTAINING AND C HANGING P OSITIONS : moving self to and from positions,
(including chair or wheelchair, standing, floor, and toilet); maintaining stable seated position on floor or toilet; maintaining functional position in seat for ½ hour of class instruction or seat work; boarding and disembarking from all vehicles.

Rev. 09/15/99
S CHOOL -R ELATED T ASKS (C ON
’
T )
R ECREATIONAL M OVEMENT : playing games involving physical activity, including throwing and catching during ball games; playing kickball; running, jumping, and climbing; and playing on both high and low playground equipment.
M
ANIPULATION WITH
M
OVEMENT
: transporting materials or belongings within and to and from classroom and in mealtime setting; carrying fragile objects or containers with spillable contents; picking up and setting down large and small objects; retrieving objects from table, storage space, or floor; opening and closing all types of doors.
U SING M ATERIALS : using all classroom tools effectively, including pencils, erasers, markers, scissors, stapler, glue, and computer; opening, closing, and turning pages in books; folding and securing papers; using art materials; and manipulating small game pieces.
S
ETUP AND
C
LEANUP
: retrieving, gathering, and putting away materials in classroom and lunchroom; opening food containers; setting up equipment or materials; disposing or waste; wiping up or tidying table top desk.
S
ELF
C
ARE
S
KILLS
: eating and drinking snack/meal using all needed utensils/ cups functionally; using a napkin to wipe face and hands; drinking from water fountain; completing toileting tasks including wiping, flushing, or managing equipment; washing and drying hands; putting on and taking off clothes as required for indoor and outdoor use, including fasteners (e.g., buttons, zippers, snaps, buckles) and shoes.
O RGANIZATION /M ATERIALS M ANAGEMENT : managing notebooks/papers/homework; keeping desk/locker space organized.
W
RITTEN
C
OMMUNICATION
S
KILLS
: meeting classroom expectations for written work
(i.e., organizing items on lines, in columns, or on a page; copying material accurately from near or far distances; sustaining physical effort on written work; and maintaining speed to keep up with peers).
G ENERAL W ORK B EHAVIORS : following classroom, mealtime, playground routines; following a series of three or more related instructions; maintaining attention to and concentration on individual and group tasks; accepting changes in routine; refraining from self- stimulatory behavior.
S AFETY : demonstrating appropriate caution around vehicles, traffic areas, electrical equipment, sharp objects; refraining from putting inedible materials in mouth; responding appropriately to established emergency signals (e.g., fire drills, etc.).
Additional Comments:
[Source: Coster, W. J., Deeney, T., Haltiwanger, J., & Haley, S. M. (1998). School Function Assessment.
San Antonio, TX: The Psychological Corporation/Therapy Skill Builders.]
F N