Functional School Performance Checklist

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Completion of this form is necessary for the OT and/or PT to determine the need for a formal evaluation. Please complete this checklist based on your daily observations of this student.

Email *

Your Name *

Todays' Date *

YYYY

Student Name *

Grade *

DOB *

YYYY

Resident School District *

Serving School and if applicable TCSE Program *

Please share ANY medical or physical conditions that may impact the student's functioning? *

Have you recently met regarding these concerns through a special education referral / INA meeting? *

Yes

Does this student have known disability and current IEP or 504? *

Yes

If YES to IEP/504, please indicate the students current IEP eligibility(s) or 504 below

Does this student wear glasses? *

Yes

Clear form

Never submit passwords through Google Forms.

This form was created inside of Tri-County Special Education JA.

Does this form look suspicious? Report

Forms