Sample Forms
Communication
- PT Satisfaction Survey (Durham)
- PT Pink Sheet (Durham)
- PT Parent Contact Form (Durham)
- PT MD Contact Form (Durham)
- PT Orthotic Referral (Durham)
- PT Intro Letter (Durham)
- PT Consult (Durham)
- Parent Questionnaire(Durham)
Equipment
- Student Equipmant Log
- LMN Log (Winston Salem)
- Protective Device Form (Durham)
- PT Loan Agreement (Durham)
- PT Waiver of Liability (Durham)
- Student Equipment Log (Winston-Salem)
Evaluations
- Bruininks Evaluation (Durham)
- Re-evaluation (Winston-Salem)
- Generic OT Evaluation
- Peabody 2 Evaluation (Durham)
- Peabody Form (Durham)
- Physical Therapy Evaluation Form
- Preschool Functional Inventory (Maryland)
- PT-Gross Motor Checklist (NYC)
- PT Functional Evaluation – Nonambulatory (Cumberland)
- PT Functional Evaluation (Cumberland)
- PT Functional Evaluation (Durham)
- PT School Function Evaluation – Middle & HS (NYC)
- PT School Function Evaluation Appendices Middle and HS (NYC)
- PT School Function Evaluation – Pre-K & Elementary (NYC)
- PT School Function Evaluation Appendices – Pre-K and Elementary (NYC)
- 国家林业局Eval达勒姆SFA
- Summary Score Form Durham
- Student Functional Inventory (Maryland)
Miscellaneous
- School Start up Checklist
- Documentation of Body Mech Training
- Gross Motor Skill Level
- Goal Achievement Analysis
- Gross Motor Skills in Sensory Diet
- PT Discharge from Services
- PT Do the Math
- PT Pamphlet
- PT Training Form
- PT Peer Review Checklist Sample
- PT Service Levels
Mobility, Safety, Evacuation
- Documentation of Wheelchair Management and Mob Training (CMS)
- Evacuation Plan for Physical Therapy (CMS)
- Functional Mobility in Education Environment (CMS)
- General Safety Assessment
- School Safety Drills for Physical Disabilities (CMS)
Organization Planning
- PT Continuing Education Record (Durham)
- PT Monthly Planner (Durham)
- PT Schedule – A (Durham)
- PT Schedule – B (Durham)
- PT To-Do List (Durham)
- PT Weekly Planner (Durham)
Plans of Care
- Generic Plan of Care
- PT POC September 2018 Form
- SBPT Plan of Care
- School PT Plan of Care
- PT Department – Plan of Care (ABSS)
- Plan of Care Template (Cleveland)
- Sample School-Based Occupational Therapy Plan of Care
- Sample School-Based Occupational Therapy Intervention Plan
- Sample School-based Psychological/Counseling Plan of Care
- Plan for Skilled Intervention/Plan of Care SLP
Positioning
- Bench Sitting on Floor
- Communication Log
- Long Sitting
- I.E.P. Team Goals and Objectives
- Positioning for Education Adaptive Equipment Handout
- Positioning for Education Desk and Chair Handout
- Positioning for Education Wheelchair Handout
- Positioning for Education Floor Time Handout (CMS)
- Procedure Log Sheet and Comments
- Prone on Wedge PF (Durham)
- Sidelyer Positioning Data Form (Durham)
- Stander Positioning Data Form (Durham)
- Tumbleforms Seat Positioning Data Form (Durham)
Related Service Support Description
- Documentation of Restroom Training (CMS)
- Restroom Data Collection (CMS)
- Restroom FAQ (CMS)
- Restroom Procedure Form (CMS)
- Restroom Strategies and Adaptive Equipment (CMS)
Sample Contracts
- Independent Contractor Sample Contract (Cleveland)
- Sample PT contract (NHC)
- Sample OTPRN Contract
- Sample PT Contract
- SLP Sample Contract
Screen Referrals
- Exceptional Children’s Program (Durham)
- Motor Screen 2.5 to 3 yr (Craven)
- Motor Screen 3 to 3.5 yr (Craven)
- Motor Screen 3.5 to 4 yr (Craven)
- Motor Screen 4 to 5 yr (Craven)
- Motor Screening (Durham)
- Motor Screening Form (Craven)
- OT and PT in Public Education
- OTPT Referral (Durham)
- OT-PT Referral Form
- PT – Gross Motor Pre-Referral Strategies
- PT Referral Checklist (Durham)
- PT Screening (Durham)
- PT Teacher Screening (NYC)
Session Documentation
- Daily Progress Note Form Filled Sample (NYC)
- PT Log 2 (Durham)
- PT日志3 (Durham)
- PT Log 4 (Durham)
- PT Monthly Planner (Durham)
- PT POCPT Weekly Planner (Durham)
Transition
- PT Student Needs School Transition Form (Durham)
- PT学生需要学校09杜伦过渡形式
- Sample Transition Letter CP CMS
- Sample Transition Letter Spina Bifida CMS
- Student Transition Checklist CMS
- Student Transition Info for PT CMS
Transportation
- Procedures for WC Tie down straps CMS
- PT Transportation Form Durham
- PT Transportation Safety List Durham
- Red Tag Ltr to Parents-Spanish Durham
- Sample Parent Notification
- Student Profile Transportation Considerations CMS
- Procedures for Bus Loading Walker-Crutches (CMS)
- Procedures for Bus Loading Wheelchair (CMS)
- Procedures for Occupant Restraint CMS
- Procedures for Using Integrated Child Restraints on the Bus (1) CMS
- Procedures for Using Safety Vests on the Bus CMS
- Procedures for Using STAR on the Bus CMS