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Ot Assessment Template - Selpa
Ot Assessment Template - Selpa
Ot Assessment Template - Selpa
CONFIDENTIAL INFORMATION
OCCUPATIONAL THERAPY ASSESSMENT REPORT
Name Grade
Birth Date School
Chronological Age Ethnicity
Report Date Testing Date(s)
The following assessment report contains sensitive and confidential information. Nonconsensual redisclosure by
unauthorized individuals is prohibited by both the California State Education Code and the Welfare and Institution
Code.
This report was developed to assist the IEP Team in determining whether the student requires occupational therapy
services to progress in and benefit from the educational placement. The decision as to whether or not the assessment
results demonstrate that the degree of the student’s impairment requires special education shall be made by the IEP
team, including assessment personnel. The IEP team shall take into account all relevant material which is available on
the student. No single score or product of scores shall be used as the sole criterion for the decision of the IEP team as
to the student’s eligibility for special education. (From CCR 5 Sec. 3030).
The purpose of this assessment is to determine the student’s areas of strengths, weaknesses, and needs, to provide
information and supportive educational strategies for further educational planning, and to assist the IEP team in
determining the student's eligibility to receive Occupational Therapy services. Education-related occupational therapy
services are school-based and directed towards adapting the environment, modifying functional tasks, and addressing
fine motor performance. In order for occupational therapy services to be recommended, deficit areas of motor and or
processing related function need to be present, and interfere with the child’s ability to function in the school
environment. In addition, these needs must be such that the special education staff cannot just address them but
require the intervention of a trained occupational therapist.
Source of referral (teacher, parent, Student Success Team, Intervention Team, DIS provider, etc.)
Primary reason why student was referred
Statement of current eligibility for OT and level of service (if not initial assessment)
Other identified concerns
NAME: DOB: REPORT DATE:
Current Evaluation
Validity Statement:
All tests were administered in the student’s primary language and were administered by qualified personnel in
accordance with the instructions provided by the test publishers. The results of the standardized assessment are
believed to be valid.
Testing and assessment materials and procedures used for the purposes of assessment of students with disabilities are
selected and administered so as not to be racially, culturally, or sexually discriminatory. Tests have been validated for
the specific purpose for which they are used and administrated by trained personnel in accordance with the instruction
of the producer [34 C.F.R. 300.532(e)]. The school occupational therapist evaluates the child within the educational
setting assessing strengths as well as what may be interfering with learning and participation in the context of existing
special education supports and services (including strategies already utilized to improve performance). Guidelines for
Occupational Therapy & Physical Therapy in California Public Schools, 2 nd edition, California Department of Education,
2010).
Student Interview:
The recommendations for OT are based on the therapist’s professional judgment and are derived from interpretation of
findings, the child’s academic achievement and functional performance. Factors that contribute to clinical reasoning
include age, expected response to therapy, possibility of needs being met by others, stability of status, and the pattern
and severity of difficulties. (Guidelines for Occupational Therapy & Physical Therapy in California Public Schools, 2 nd
edition, California Department of Education, 2010)
Assessment Summary:
The summary should consist of one or two paragraphs that provides a brief description of relevant
background information and the assessment findings.
Name, referral question, age, grade, ethnic background, EL status, instructional program
Brief review of relevant background information (attendance, educational history, etc.)
Impact of skills on functioning in the general education classroom
Assessment Conclusions:
Based on the results of this report, the student appears to/ does not appear to meet eligibility for occupational
therapy services at this time.
Rationale:
NOTE: A student must meet educational eligibility criteria, regardless of medical diagnosis.
If a student no longer qualifies in an area in which they previously qualified, please explain in detail the
rationale behind the student no longer meeting eligibility in that area.
The IEP team will meet to discuss assessment results and will make final determinations regarding special
education eligibility and services at that time.
Recommendations
The following interventions are intended as suggested strategies to facilitate learning and not to be interpreted as
accommodations mandated in an IEP.
Each student will have a different set of needs due to their unique profile. Thus, the recommendations
should be individualized.
Occupational Therapy services should not be recommended if the student is not eligible for special
education under an eligibility category as noted by the psycho-educational assessment report. Please work
in conjunction with the rest of the IEP team to prevent recommending services when a student is not
eligible.
NAME: DOB: REPORT DATE:
Recommendations should not include 1:1 aide, discussion of placement, service minutes, etc. These are all
decisions of the IEP team.
____________________________________ ____________________________________
Mr./Ms./Mrs.OT Date
Occupational Therapist