PSU/LEA Shared Resources and Forms
Click on the categories below to view sample forms.
You must download or copy the forms to edit.
You must download or copy the forms to edit.
(These forms & resources have been shared by your fellow colleagues across the state!)
- PT Satisfaction Survey (pdf) (doc) – provided by Durham Public Schools
- PT Pink Sheet | Durham (pdf) (doc) – provided by Durham Public Schools
- PT Parent Contact Form (pdf) (doc) – provided by Durham Public Schools
- PT MD Contact Form (pdf) (doc) – provided by Durham Public Schools
- PT Orthotic Referral (pdf) (doc) – provided by Durham Public Schools
- PT Intro Letter (pdf) (doc)– provided by Durham Public Schools
- PT Consult (pdf) (doc)– provided by Durham Public Schools
- PT Pamphlet (pdf) (doc) – provided by Durham Public Schools
- Parent Questionnaire (pdf) (doc) – provided by Durham Public Schools
APTA Pediatric Resource-Management of Equipment Used by Physical Therapists in School-Based Practice
- Student Equipment Log (pdf) (doc) – provided by Winston-Salem/Forsyth County Schools
- LMN Log (pdf) (doc) – provided by Winston-Salem/Forsyth County Schools
- Protective Device Form (pdf) (doc) – provided by Durham Public Schools
- PT Loan Agreement (pdf) (doc) – provided by Durham Public Schools
- PT Waiver of Liability (pdf) (doc) – provided by Durham Public Schools
- Student Equipment Log (pdf) (doc) – Winston-Salem/Forsyth County Schools
- Section 504 Individualized Eligibility Report – provided by Weldon City
- Bruininks Evaluation (pdf) (doc) – provided by Durham Public Schools
- Re-evaluation (pdf) (doc) – Winston-Salem/Forsyth County Schools
- Generic OT Evaluation (pdf) (doc)
- Peabody 2 Evaluation (pdf) (doc) – provided by Durham Public Schools
- Peabody Form (pdf) (doc) – provided by Durham Public Schools
- Physical Therapy Evaluation Form (pdf) (doc)
- Preschool Functional Inventory (pdf) (doc) – Maryland
- PT-Gross Motor Checklist (pdf) (doc) – provided by NYC
- PT Functional Evaluation – Nonambulatory (pdf) (doc) – provided by Cumberland County Schools
- PT Functional Evaluation (pdf) (doc) – provided by Cumberland County Schools
- PT Functional Evaluation (pdf) (doc) – provided by Durham Public Schools
- PT School Function Evaluation – Middle & HS (pdf) (doc) – provided by NYC
- PT School Function Evaluation Appendices Middle and HS (pdf) (doc) – provided by NYC
- PT School Function Evaluation – Pre-K & Elementary (pdf) (doc) – provided by NYC
- PT School Function Evaluation Appendices – Pre-K and Elementary (pdf) (doc) – provided by NYC
- SFA Eval SFA (pdf) (doc) – provided by Durham Public Schools
- Summary Score Form (pdf) (doc) – provided by Durham Public Schools
- Student Functional Inventory (pdf) (doc) – Maryland
- Tests & Measures Cheat Sheet – provided by NYC
- An Example of language for a contingency plan – “Physical therapist will provide guidance and instruction to facilitate progress of foundational skills necessary for functional mobility goal attainment during direct virtual physical therapy services.” – Newton Conover City Schools
- Documentation of Body Mech Training (pdf) (doc) – provided by CMS
- Grid Game, Submitted by Rockingham Co Schools
- List of Therapy Activities in Video Library – permission was not granted for the original videos to be posted publicly, however this list will give you ideas of videos you can create on your own. – Pitt County Schools
- I Am Here: A Booklet About Mindfulness, by Eleanor Cole
- School Start up Checklist (pdf) (sheet) – provided by Durham Public Schools
- Goal Achievement Analysis (pdf) (doc) – provided by New Hanover County Schools
- Gross Motor Skills in Sensory Diet (pdf) – provided by New Hanover County Schools
- PT Discharge from Services (pdf) (doc) – provided by Durham Public Schools
- PT Do the Math (pdf) (doc)
- PT Peer Review Checklist Sample (pdf) (doc) – provided by Durham Public Schools
- PT Service Levels (pdf) (doc) – Winston-Salem/Forsyth County Schools
- Documentation of Wheelchair Management and Mob Training (pdf) (doc) – provided by CMS
- Evacuation Plan for Physical Therapy (pdf) (doc) – provided by CMS
- Functional Mobility in Education Environment (pdf) (doc) – provided by CMS
- General Safety Assessment (pdf) (doc)
- PT Training Form (pdf) (doc) – provided by Durham Public Schools
- School Safety Drills for Physical Disabilities (pdf) (doc) – provided by CMS
- PT Continuing Education Record (pdf) (doc) – provided by Durham Public Schools
- PT Monthly Planner (pdf) (doc) – provided by Durham Public Schools
- PT Schedule – A (pdf) (doc) – provided by Durham Public Schools
- PT Schedule – B (pdf) (doc) – provided by Durham Public Schools
- PT To-Do List (pdf) (doc) – provided by Durham Public Schools
- PT Weekly Planner (pdf) (doc) – provided by Durham Public Schools
- Generic Plan of Care (pdf)
- PT POC Form (pdf)
- SBPT Plan of Care (pdf)
- School PT Plan of Care (pdf) (doc)
- PT Department – Plan of Care (pdf) (doc) – provided by ABSS
- Plan of Care Template (pdf) (doc) – provided by Cleveland County Schools
- Sample School-Based Occupational Therapy Plan of Care (pdf) (doc)
- Sample School-Based Occupational Therapy Intervention Plan (pdf) (doc)
- Sample School-based Psychological/Counseling Plan of Care (pdf) (doc)
- Plan for Skilled Intervention/Plan of Care SLP (pdf) (doc)
- Bench Sitting on Floor (pdf) (doc)
- Communication Log (pdf) (doc)
- Long Sitting (pdf) (doc)
- I.E.P. Team Goals and Objectives (pdf) (doc)
- Positioning for Education Adaptive Equipment Handout (pdf) (doc)
- Positioning for Education Desk and Chair Handout (pdf) (doc)
- Positioning for Education Floor Time Handout (pdf) (doc) – provided by CMS
- Positioning for Education Wheelchair Handout (pdf) (doc)
- Procedure Log Sheet and Comments (pdf) (doc)
- Prone on Wedge PF (pdf) (doc) – provided by Durham Public Schools
- Sidelyer Positioning Data Form (pdf) (doc) – provided by Durham Public Schools
- Stander Positioning Data Form (pdf) (doc) – provided by Durham Public Schools
- Tumbleforms Seat Positioning Data Form (pdf) (doc) – provided by Durham Public Schools
- Exceptional Children’s Program (pdf) (doc) – provided by Durham Public Schools
- Gross Motor Skill Level (pdf) (doc) – provided by New Hanover County Schools
- Motor Screen (pdf) – provided by Randolph County School System
- Motor Screen 2.5 to 3 yr (pdf) (doc) – provided by Craven County Schools
- Motor Screen 3 to 3.5 yr (pdf) (doc) – provided by Craven County Schools
- Motor Screen 3.5 to 4 yr (pdf) (doc) – provided by Craven County Schools
- Motor Screen 4 to 5 yr (pdf) (doc) – provided by Craven County Schools
- Motor Screen for Preschoolers (pdf) – provided by Randolph County School System
- Motor Screening (pdf) (doc) – provided by Durham Public Schools
- Motor Screening Form (pdf) (doc) – provided by Craven County Schools
- Motor Screening Tool (pdf) – provided by Buncombe County Schools
- OT and PT in Public Education (pdf) (doc)
- OT-PT Referral (pdf) (doc) – provided by Durham Public Schools
- OT-PT Referral Form (pdf) (doc)
- PT – Gross Motor Pre-Referral Strategies (pdf) (doc)
- PT Referral Checklist (pdf) (doc) – provided by Durham Public Schools
- PT Screening (pdf) (doc) – provided by Durham Public Schools
- PT Teacher Screening (pdf) (doc) – provided by NYC
- School Function Motor Screen (pdf) – provided by Randolph County School System
- Daily Progress Note Form Filled Sample (NYC) (pdf) (sheet)
- Student Service Information/Attendance Log (pdf) (doc) – provided by Durham Public Schools
- Daily Progress Notes (pdf) (doc) – provided by Durham Public Schools
- Progress Note (pdf) (doc) – provided by Durham Public Schools
- Sample Goal Data Collection (pdf) (doc)
- PT Attendance Log (pdf) (doc) – provided by Durham Public Schools
- PT Record (pdf) (doc) – Winston-Salem/Forsyth County Schools
- PT Therapeutic Log (pdf) (doc) – provided by Durham Public Schools
- PT Student Needs School Transition Form (pdf) (doc) – provided by Durham Public Schools
- Sample Transition Letter CP (pdf) (doc) – provided by CMS
- Sample Transition Letter Spina Bifida (pdf) (doc) – provided by CMS
- Student Transition Checklist (pdf) (doc) – provided by CMS
- Student Transition Info for PT (pdf) (doc) – provided by CMS
- Telehealth Transition Checklist (CMS)
- Procedures for Bus Loading Walker-Crutches (pdf) (doc) – provided by CMS
- Procedures for Bus Loading Wheelchair (pdf) (doc) – provided by CMS
- Procedures for Occupant Restraint (pdf) (doc) – provided by CMS
- Procedures for Using Integrated Child Restraints on the Bus (pdf) (doc) – provided by CMS
- Procedures for Using Safety Vests on the Bus (pdf) (doc) – provided by CMS
- Procedures for Using STAR on the Bus (pdf) (doc) – provided by CMS
- Procedures for Wheelchair Tie down straps (pdf) (doc) – provided by CMS
- PT Transportation Form (pdf) (doc) – provided by Durham Public Schools
- PT Transportation Safety List (pdf) (doc) – provided by Durham Public Schools
- Red Tag Letter to Parents-Spanish (doc) – provided by Durham Public Schools
- Student Profile Transportation Considerations (pdf) (doc) – provided by CMS
- Transportation Form – provided by Pitt County Schools