Each evaluator generates written evaluation summary that addresses the reason for referral and includes the procedures used, the results, and the diagnostic impression, as well as a detailed description of the student’s needs, with explicit means of meeting them.

The occupational therapy evaluation report includes an analysis of the assessment results and occupational profile information that contribute to the understanding of the student’s strengths and weaknesses as they relate to the reason for referral. This information is presented concisely in the written occupational therapy evaluation report and presented/summarized at the team meeting.

The OT Evaluation Report

~Provides information to help the team  understand the student

~Explains the student’s abilities and challenges in relation to school participation

~Identifies accommodations or strategies needed to enable student participation

Comprehensive, quality evaluation reports provide the team with information necessary to make sound eligibility determinations and to write appropriate IEPs. A well-written evaluation report can also reduce the likelihood that an independent evaluation will be necessary. There is currently no mandated format for the written evaluation report. IDEA 2004 does not provide explicit guidelines for the format and content of evaluation reports. State laws and regulations may contain requirements specific to the content and format of evaluation reports. The format of the occupational therapy evaluation report is dynamic and changes based on changes to special education law and the OT Practice Framework.

Evaluation Reports typically include the procedures used, the results, the diagnostic impression, a detailed description of the student’s needs,
and explicit means of meeting the student’s needs. In addition, evaluation reports are written in clear, jargon-free language, address the specific reason for referral, provide information regarding the possible presence or absence of a disability and, interpret assessment results related to the student’s performance in school (i.e. does the disability affect the student’s participation in the educational program?).

There are many ways in which an evaluation report may be structured. One possible format could reflect the OT Practice Framework by including the following sections:

1. Heading

Student name

Student date of birth/age

School/District

Grade

Date of evaluation

Evaluator name, credentials and role

 

2. Occupational Profile

Reason for referral

Background information

Current services and strategies/accommodations

Teacher interview/perspective/needs (and other school staff)

Parent interview/perspective/needs

Student interview/perspective/needs

 

3. Analysis of Occupational Performance

Summary of contextual observation of student (based on reason for referral)

Behavioral observations during testing

Results of standardized and non-standardized assessment tools and strategies

Interpretation and Summary of results including a detailed description of the student’s needs in relation to participation in their educational program and the life of the school*

Recommendations** including the accommodations or strategies needed to enable the student to participate, i.e. explicit means for meeting the identified needs.

 

*Areas identified as interfering with school participation are address through the special education process. Areas noted that do not interfere with school participation are acknowledged but not addressed through the special education process. Parents have the option of addressing these issues on their own outside of the school setting. The OT must be clear in their role within the public school setting and be prepared to clearly relay this information to the parents and other team members. For more information visit the OT Role section of this website.

**Recommendations for related services, including occupational therapy, are ultimately a team decision according to special education process.  Eligibility for special education and recommendations for specific services are determined at the team meeting and are not known at the time the initial evaluation report is being written. Specific service delivery recommendations (e.g. OT 2 times weekly for 30 minute sessions) are not typically included in the initial evaluation report.  Recommendations should include specific and individualized accommodations and strategies designed to improve student participation in the classroom (ex. frequent breaks from seated work, use of bold-lined paper, positioning the child first in line when transitioning out of the classroom, etc.) and activities to address skill deficits (ex. review of letter formation and short daily guided practice sessions, prone position for home activities to increase postural strength, practice zipping coat with specific procedure/instructions daily when preparing for recess and departing school, etc.). While the team may determine that some of these recommendations may ultimately be addressed by OT, they are written in such a way as to leave open the decision of who and how these recommendations will be implemented.