School-Based OT Evaluation Report (IEP/504)

School-Based Occupational Therapy Evaluation Report (IEP/504)

Student Name: [Student legal name]

Date of Birth / Age / Grade: [DOB] / [Age] / [Grade]

School / District: [School] / [District]

Student ID: [District/State ID] (Omit if not used by district)

Teacher / Case Manager: [Name and role]

Evaluation Type: [Initial OT Evaluation / Reevaluation / Screening-Record Review] — [IEP / Section 504 / eligibility under consideration]

Referral Date: [Referral date]

Parent/Guardian Consent Date: [Consent date] (If missing: "Not provided—verify before finalizing.")

Assessment Date(s): [Dates of assessment activities]

Report Date: [Date report finalized]

Evaluator: [Name, credentials (e.g., OTR/L), contact information] (If credentials unavailable: "Not provided—verify before finalizing.")

Participants/Informants: [Parent/guardian(s), teacher(s), student, related staff who provided input]

Language Considerations: [Student primary language; language of instruction; interpreter used: yes/no] (Note bilingual assessment considerations if applicable.)

Confidentiality: Educational record—share per district policy and FERPA.

Referral Information

[Referring source, reason for referral, and educational participation concerns prompting evaluation] (Frame as participation barriers using functional, school-based language rather than impairment labels.)

Primary Participation Concerns:

• [Participation concern] (e.g., task initiation, written output within time, organization, transitions)
• [Additional concerns as needed]

Pre-referral Supports and Response:

• [MTSS/RTI or classroom strategy attempted, duration] — [Student response with data if available]
• [Additional interventions as applicable]
• (If intervention history unknown: "Records did not indicate prior interventions related to referral concerns.")

This evaluation focuses on school participation and educational access.

Background Information

[Brief narrative summary of relevant context impacting school function]

• Current placement and services: [Educational setting, minutes, related services]
• Teacher concerns: [Summary with clarifying direct quote if helpful]
• Parent/caregiver input: [Summary of priorities and concerns] (If not obtained, document contact attempts and note limitation.)
• Student voice: [Strengths, interests, perceived challenges] (Include if student participated.)
• Relevant history impacting school function: [Brief, relevant items with source]
• Current tools/AT in use: [Pencil grips, adapted paper, keyboards, seating, visual schedules, etc.]

Evaluation Methods

[Overview of participation- and curriculum-focused assessment approach]

• Records reviewed: [IEP/504, teacher reports, grades, work samples, prior evaluations]
• Interviews: [Names/roles, dates, key topics]
• Observations: [Settings, activities, dates/times, environmental conditions]
• Standardized assessments: [Full instrument name, edition, norms, scoring metric] (Include rationale for selection.)
• Non-standardized tools/checklists: [Names and focus areas]
• Work samples analyzed: [Type, dates, context]
• Accommodations during assessment: [Interpreter, breaks, visual supports, AT, nonstandard administration]
• Validity considerations: [Factors affecting interpretation and mitigations used]

(If standardized assessments not used: "The referral question was best addressed through ecological observation and curriculum-linked work sampling.")

Observations

(Document observations in natural school contexts using objective, descriptive language.)

Context: [Setting, activity/task, date/time, environmental conditions]

• Participation and independence: [Description of engagement and independence level]
• Prompting required: [Type and frequency] (e.g., verbal/gestural/visual/physical; frequency)
• Peer comparison: [Functional comparison to classroom expectations]
• Motor/postural factors: [Observed impact on school tasks]
• Arousal/regulation: [Arousal level, regulation strategies, triggers observed]
• Effective supports: [Strategies or environmental features that improved performance]
• Work samples referenced: [Description and date]

(Repeat observation format for additional contexts as needed.)

Assessment Findings

(Address only domains pertinent to referral. Translate results into school-based functional implications. Triangulate standardized scores with observations and work samples. Report each data point once.)

[Domain title relevant to referral]

(Common domains include: fine motor and tool use; handwriting and written output; visual-motor and visual-perceptual skills; sensory processing and self-regulation; executive function and organization; classroom participation skills; school self-care. Include only those relevant to this student.)

Functional performance: [Description tied to classroom tasks]

• Supporting data: [Observations, work samples, scores with interpretive category]
• Interpretation and school impact: [What results mean for participation and access]
• Effective supports and barriers: [Strategies that helped; conditions that hindered]

(Repeat domain format for each relevant area. For domains not assessed with no reported concerns: "[Domain]—not assessed; no concerns reported or observed.")

Summary and Educational Impact

Strengths

• [Participation-focused strength] (e.g., responds well to visual schedules, strong verbal expression)
• [Additional strengths]

Needs

• [Participation-focused need] (e.g., written output insufficient to demonstrate knowledge within time)
• [Additional needs]

Educational Impact Statement

[Concise paragraph explicitly linking OT-relevant barriers to involvement and progress in the general education curriculum and school routines, grounded in documented data. Note accommodations or strategies that improved participation.]

Eligibility Considerations

OT-related functional need: [Findings demonstrate / Findings do not demonstrate] an educationally relevant functional need within OT's domain.

For IEP (IDEA)

Occupational therapy is considered a related service to support access to and benefit from the IEP. Eligibility determination is made by the IEP team; this report provides evaluation findings and recommendations. [Summary of how OT services/accommodations would support IEP goal access, if applicable.]

For Section 504

Functional limitation(s): [Summary as related to school access and participation]

OT-relevant accommodations needed: [Accommodations for equal access]

Eligibility determination is made by the 504 team.

(Include IEP or 504 section based on evaluation type; include both if eligibility framework is under consideration.)

Recommendations

(Provide actionable, school-based recommendations. Do not recommend non-school services as school requirements.)

Accommodations and Supports

• [Task/environment modifications] (e.g., adapted paper, seating/positioning, reduced copying)
• [Instructional supports] (e.g., visual models, checklists, chunking)
• [Access accommodations] (e.g., extended time when justified by data, keyboarding)
• [Regulation supports] (e.g., scheduled movement, noise management, calm corner)

OT Service Delivery

(If services indicated:) Recommend [consultation / classroom-based / small group / individual] at [frequency/duration] focused on [functional outcomes tied to participation]. Final service decisions are made by the IEP/504 team.

Assistive Technology

(If AT recommended:)

• Proposed tool(s): [e.g., keyboarding, word prediction, speech-to-text]
• Trial plan: [Context, duration, training, responsible staff]
• Success criteria: [Measurable participation outcomes indicating benefit]

Staff Training

• [Training topic, target staff, materials needed]

Progress Monitoring

• Indicators: [Measurable indicators such as legibility rubric %, words per minute, independence level, prompts required]
• Baseline: [Current data point(s) with date]
• Review interval: [Timeframe aligned with team schedules]
• Data collection method: [Rubric / frequency count / work sample analysis / timing]

(If outside referral may benefit student: "Family may consider discussing [concern] with primary care provider.")

Signature

Evaluator Signature: ____________________

Printed Name and Credentials: [Name, OTR/L]

Date: [Date signed]

I certify this report reflects my professional findings based on the data described above.

(If OTA contributed, include co-signature per state/district requirements.)