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    Adapted Physical Education Pre-referral Checklist*

     

    Child’s Name: ______________________________________________ Date:  _________________

     

    Person Completing Form/Job Title: ____________________________________________________

     

    Rate each item based on how the child compares to other children in his/her physical education class.

     

    Does the child have significant difficulties (as compared to other children) in activities that require strength (throwing or kicking for distance, push-ups or sit ups)?

     

    yes          no

     

     

    Does the child seem to be excessively fatigued (as compared to other children), and does this affect the child’s attention or participation?


        yes          no

     

     

    Does the child display a significant lack of willingness or interest in participating in physical activities (as compared to peers)(prefers to play alone at recess, tries to get out of physical activities)?

       

    yes          no

     

     

     

    Does the child have significant difficulty with posture or balance (can’t stay seated in chair, displays excess or unnecessary movements, falls, leans on desk or wall)?

     

     

        yes          no

     

     

    Does the child have significantly more trouble than peers when performing activities that require motor-planning (starting a movement, carrying out physical tasks in sequence)?

       

    yes          no

     

     

    Does the child have trouble keeping up with peers in physical activities (tires easily, move very slowly, is not able to participate in physical tasks efficiently or completely)?

       

    yes          no

     

     

    Does the child have significant difficulty in ball skills compared to peers (cannot catch, throw, strike or kick with pattern expected of age or does not perform skills smoothly as compared to similar age peers)?

        yes          no

     

     

    Does the child display general clumsiness or awkwardness that is significantly greater than peers (lacks coordination and smoothness of movement, looks “different” when moving)?

       

       yes          no

     

     

    Is the child unsafe in a specific situation or setting (falls, is unable to control body movements, does not have awareness of body in space, bumps into others in line or when moving in the gym often and without awareness)?

        yes          no

     

     

    Do the difficulties that you notice seem to be getting worse with time (over last 6 months), or do they worsen under situations of stress of excitement (loud or complex environments, new situations, specific time of day?

       yes          no

     

     

    ·         If you answered yes to 1 or 2 questions, child probably does not need a referral to APE

    ·         If you answered yes to 3 or more questions, then a referral for APE evaluation may be appropriate.

     

    Other Comments:______________________________________________________________________________________

     

    _______________________________________________________________________________________________

     

    _______________________________________________________________________________________________

     

     

     

     

    *adapted from Dole, R.L. (2004). Collaborating successfully with your school’s physical therapist.    TEACHING Exceptional Children, 36,(5), 28-35.