FINE AND GROSS MOTOR DATA SHEET & SCREENER
Student______Teacher______Grade______School______
Return to______Date:______
FINE MOTOR SKILLS **please include a copy of ANY writing sample or rubric______
_____Fine Motor skills appear as expected for age/grade level 80-100% and do not interfere with accessing
school curriculum and/or independence within the school environment
_____Fine Motor skills appear functional 80-100% (even if not age/grade appropriate) and do not significantly
interfere with accessing school curriculum and/or independence within the school environment
_____Fine Motor skills appear delayed 80-100% and significantly interfere with accessing school
curriculum and/or independence within the school environment
*** Check areas of significant concern:
_____ handwriting legibility _____letter formation/line orientation _____number formation
_____rate of writing _____cutting _____art type projects
_____copying _____coloring
_____spacing _____clothing fasteners (zip coat, tie shoes)
_____GROSS MOTOR SKILLS (mobility, playground, posture)______
_____Gross Motor skills appear as expected for age/grade level 80-100% and do not interfere within the school
environment
_____Gross Motor skills appear functional 80-100% (even if not appropriate for age/grade level) and do not
significantly interfere within the school environment
_____Gross Motor skills appear delayed 80-100% and significantly interfere within the school environment
***Check areas of concern:
_____mobility throughout the school _____sitting posture on floor _____accessing playground
_____mobility within the classroom _____sitting posture chair/desk
______SENSORY check behaviors that frequently (80-100%) interfere within the school setting_____
_____tires easily, poor posture, awkward _____distracted/bothered by noise, covers ears
_____seeks movement, fidgets with items _____difficulty in line, dislikes “messy” things
_____chews on inappropriate items _____over reacts or dislikes changes to routine
*If you have used sensory supports what type works best for this student?
_____movements breaks _____headphones
_____quiet, alone spot _____designated area in line or in class
_____weight bearing, deep pressure, weighted toys _____structure, schedule
_____fidgets
Completed by: ______Date:______
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
OT/PT Screen of Student Information
Next steps:
Fine and Gross motor skills do not interfere with academic success and no further testing is required.
Fine motor skills/Sensory needs are a concern in the school environment. Informal/formal testing required.
Gross motor skills are a concern in the school environment and a PT referral will be completed.
Becky Delaroy, OTR/L ADAMS 12 2014