1234 School Address

Pretty City, CA 12345

Ph. 555-444-4444
Fx. 555-555-5555
School Website

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).

A Note on the Use of the Template:

This template is not intended to be utilized as a sample report. It is recommended that all items in RED be
REMOVED as these items have only been included to provide suggestions of information you may wish to
incorporate, and not intended to remain in the report. All information presented within the headings in this
template should be written for the ease of understanding for all IEP participants and be written in paragraph
format instead of using bullet points. Not all sections of the report are required, therefore removal of sections is
recommended depending on the assessment that was completed and the student for whom it was completed.

Reason for Referral

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
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 Access to interventions and response

 EXAMPLE: Student is a 1st grade student attending a general education class at Lone Tree
Elementary. Student qualifies for special education under the primary eligibility of Autism and
secondary of Speech and Language Impairment. He currently receives occupational therapy (OT)
services at 30 minutes per session 1 time per week.

Background Information Relevant to This Report

 History of the service

 Type of service offered
 Type of assessment
 EXAMPLE: Student started receiving OT services under a consultation model in January 2013 to
address sensory processing needs. In December 2013, direct occupational therapy services were
added following an assessment that indicated delays in cutting and copying shapes. This
Occupational Therapy assessment is part of Student’s triennial review. Please refer to recent psycho-
educational evaluation for further background information.

Previous Assessment(s): (remove if initial)

Date Type Assessor Summary of Data
8/13/1 Test of Visual Mrs. OT
2 Processing
7/22/1 Beery Visual Mr. Occupation
2 Motor Integration

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).

Procedures for Evaluation:

 Interview with classroom teacher
 Review of work samples
 Clinical observations
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 Beery VMI (6th Ed.)

 Other (add here based on individual assessment)

Relation of observed behavior to results of assessment:

 Behavior during testing, including relationship of behavior to the reliability of the current assessment
results.
 Glasses or hearing aids worn during testing if necessary?
EXAMPLE: Accommodations made during this assessment were frequent opportunities for movement, breaks
and praise for her efforts. No modifications were provided during assessment. On the day of the assessment,
Student happily transitioned to the testing area. He demonstrated interaction and eye contact with the assessor.
Student performed all tasks presented to him, gave his best effort, and maintained a positive attitude even
through challenging tasks. This assessment is likely a good representation of the student’s skills.

Observations and Interviews

Occupational Therapist Observations:

 Observations in classroom and other appropriate settings in areas of both strength and weakness,
including relationship of skills observed to academic functioning.

Teacher Observation and/or Interview:

Parent Observation and/or Interview:

Student Interview:

Current Assessment Results

Visual Processing Domain:

 Name and description of tests administered
 Test Results
 Summary

Motor Skills Development Domain:

 Handedness (Indicate right or left-handed or ambidextrous.)
 Fine Motor Skills
o Writing or printing skills
 Ease with which student uses writing tools
 Facility with using the keyboard
o Standardized testing results if applicable
o Examiner, teacher, parent observations of fine-motor skills
 Gross motor skills
o General statement utilizing examiner, teacher, parent observations/report
o Report card grades in Physical Education (PE)
 If student is receiving Designated Instruction Services (DIS), e.g. APE, PT, OT, etc.
o Make reference to service (i.e. brief history of service, current goal, time/ frequency of service).
o Summarize assessment if one was completed.
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Summary and Conclusions

Role of School-Based Occupational Therapy as an Educationally Related Service:

Under the law, OT services are based on educational need, not whether the child would benefit in some other way from
occupational therapy (34 CFR 300.346). OT services in a school setting are not intended to maximize skill level, but
rather to develop as much as possible the foundations necessary for the child to benefit from his or her individualized
educational plan (IEP). According to California Code of Regulation, Title 5, Section 56363(a), related services, “as
specified in the individualized education program shall be available when the instruction and services are necessary for
the pupil to benefit from his or her instructional program.”

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.
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 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