ETR
Evaluation Team Report
Child’s Name:

ID NUMBER:
DATE OF BIRTH:
INDIVIDUAL EVALUATOR’S ASSESSMENT
Section to be completed by each individual evaluator.
Evaluator Name:
Position:
AREAS OF ASSESSMENT: Fine Motor Skills
Indicate the area(s) that were assessed by the evaluator in accordance with the evaluation plan.
EVALUATION METHODS AND STRATEGIES
Indicate the types of assessment strategies used to gather information about the child’s performance
OBSERVATIONS
SCIENTIFIC, RESEARCH-BASED
INTERVENTIONS
INTERVIEWS
REVIEW OF RECORDS AND
RELEVANT TREND DATA (SCHOOL
RECORDS, WORK SAMPLES,
EDUCATIONAL HISTORY)
CURRICULUM BASED ASSESSMENTS
NORM-REFERENCED ASSESSMENTS
CLASSROOM BASED ASSESSMENTS
OTHER (Specify)
ASSESSMENT INFORMATION
Provide a summary of the information obtained from the assessment results per the evaluation plan including the child’s strengths, areas of
need and baseline data.
To the teacher: Please read and consider each item carefully. Place a check mark before any item
which is characteristic of the student.
SUMMARY OF ASSESSMENT RESULTS:
____ Irregular eye movements.
____ Poor body control (i.e. frequently bumps into desks, walls, other children, etc…)
____ Difficulty holding onto things/drops items frequently.
____ Motor activity involves unnecessary or inefficient movement of body parts.
____ Difficulty with eye-hand tasks.
____ Difficulty holding a pencil correctly and applying appropriate pressure.
____ Written work is poorly spaced and disorderly.
____ Difficulty using scissors.
____ Difficulty folding paper or drawing lines as directed by teacher.
____ Difficulty working at or crossing midline.
____ Does not use one hand consistently for writing and other motor tasks.
ETR
Evaluation Team Report
____ Other motor problem(s). Describe: _______________________________________________
________________________________________________________________________________
____ Motor skills contribute to difficulty with academic work. Describe: _______________________
________________________________________________________________________________
DESCRIPTION OF EDUCATIONAL NEEDS:
To the teacher: Based on the information provided above, prioritize important areas of need, related to
the student’s educational success. Continue on back if needed.
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IMPLICATIONS FOR INSTRUCTION AND PROGRESS MONITORING:
To the teacher: Summarize how the Educational Needs impact the student’s progress in the general
education curriculum. Each of the educational needs identified in the previous section should be
addressed by including a summary of the types of supports, services, or specially designed instruction, if
appropriate, that is necessary to address those needs and to enable the child to progress in the general
education curriculum.
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Evaluator’s Signature
Date