Field Name |
Description |
---|---|
Demographic Information: | |
Preferred Drawing Hand |
The examinee’s hand (right or left) most preferred for drawing activities. |
Preferred Throwing Hand/Arm |
The examinee’s hand/arm (right or left) most preferred for throwing activities. |
Preferred Foot/Leg |
The examinee’s foot/leg (right or left) most preferred for physical activities. |
Types of push-ups performed |
The examinee’s push-up position administered (knee or full). |
In School |
The examinee’s current enrollment status at an educational institution. |
Current Grade or Highest Grade Completed |
The examinee’s current grade or highest grade completed. |
Ethnicity |
The examinee’s race. |
Testing Site |
Testing site utilized. |
School/Clinic |
The examinee’s school or clinic. |
Classification/Diagnosis |
The examinee’s classification/diagnosis. |
Reason for Assessment |
The examinee’s purpose of evaluation. |
Other Information |
|
Background and Behavioral Observations: | |
Are there any considerations that may affect the accuracy of these scores? |
Allows the examiner to describe any considerations that may affect the accuracy of the scores. (500 characters) |
Were accommodations made for physical impairments? |
Allows the examiner to describe any accommodations made during testing due to physical impairments. (500 characters) |
Rate the examinee's performance in the following categories: | |
Attention |
Reflects the examinee’s level of attention to the tasks that he/she was asked to complete. (Poor, Marginal, Good, or Excellent) |
Fluidity of Movement |
Reflects the examinee’s fluidity of movement while performing tasks that he/she was asked to complete. (Poor, Marginal, Good, or Excellent) |
Effort |
Reflects the examinee’s level of effort while performing the tasks that he/she was asked to complete. (Poor, Marginal, Good, or Excellent) |
Understanding |
Reflects the examinee’s level of understanding of the tasks that he/she was asked to complete. (Poor, Marginal, Good, or Excellent) |
Scores can be entered using the Item Raw Score (IRS) or the Total Point Score (TPS).
Note: Values in parentheses represent raw score ranges.
Field Name |
Description |
---|---|
Fine Motor Precision (0 to 41) |
7 subset components: Filling in Shapes—Circle (0 to 3) Filling in Shapes—Star (0 to 3) Drawing Lines through Paths—Crooked (0 to 99) Drawing Lines through Paths—Curved (0 to 99) Connecting Dots (-10 to 12) Folding Paper (0 to 12) Cutting Out a Circle (0 to 12) |
Fine Motor Integration (0 to 40) |
8 subtest components: Copying a Circle (0 to 4) Copying a Square (0 to 5) Copying Overlapping Circles (0 to 6) Copying a Wavy Line (0 to 4) Copying a Triangle (0 to 5) Copying a Diamond (0 to 5) Copying a Star (0 to 5) Copying Overlapping Pencils (0 to 6) |
Manual Dexterity (0 to 45) |
5 subtest components: Making Dots in Circles (0 to 80) Transferring Pennies (0 to 20) Placing Pegs into a Pegboard (0 to 30) Sorting Cards (0 to 50) Stringing Blocks (0 to 15) |
Bilateral Coordination (0 to 24) |
7 subtest components: Touching Nose with Index Fingers—Eyes Closed (0 to 4) Jumping Jacks (0 to 5) Jumping in Place—Same Sides Synchronized (0 to 5) Jumping in Place—Opposite Sides Synchronized (0 to 5) Pivoting Thumbs and Index Fingers (0 to 5) Tapping Feet and Fingers—Same Sides Synchronized (0 to 10) Tapping Feet and Fingers—Opposite Sides Synchronized (0 to 10) |
Balance (0 to 37) |
9 subtest components: Standing with Feet Apart on a Line—Eyes Open (0.0 to 10.0) Walking Forward on a Line (0 to 6) Standing on One Leg on a Line—Eyes Open (0.0 to 10.0) Standing with Feet Apart on a Line—Eyes Closed (0.0 to 10.0) Walking Forward Heel-to-Toe on a Line (0 to 6) Standing on One Leg on a Line—Eyes Closed (0.0 to 10.0) Standing on One Leg a on a Balance Beam—Eyes Open (0.0 to 10.0) Standing Heel-to-Toe on a Balance Beam (0.0 to 10.0) Standing on One Leg on a Balance Beam—Eyes Closed (0.0 to 10.0) |
Running Speed and Agility (0 to 52) |
5 subtest components: Shuttle Run (1.0 to 99.9) Stepping Sideways over a Balance Beam (0 to 99) One-Legged Stationary Hop (0 to 99) One-Legged Side Hop (0 to 99) Two-Legged Side Hop (0 to 99) |
Upper-Limb Coordination (0 to 39) |
7 subtest components Dropping and Catching a Ball—Both Hands (0 to 5) Catching a Tossed Ball—Both Hands (0 to 5) Dropping and Catching a Ball—One Hand ( 0 to 5) Catching a Tossed Ball—One Hand (0 to 5) Dribbling a Ball—One Hand (0 to 10) Dribbling a Ball—Alternating Hands (0 to 10) Throwing a Ball at a Target (0 to 5) |
Strength—[Knee] or [Full] Push-ups (0 to 42) |
5 subtest components Standing Long Jump (0 to 999) 2a. Knee
Push-ups Sit-ups (0 to 99) Wall Sit (0 to 60) V-up (0 to 60) |
Notes & Observations |
Examiner provided Notes & Observations for each subtest. |
Field Name |
Description |
---|---|
Fine Motor Precision |
2 subtest components: Drawing Lines through Paths—Crooked (0 to 99) Folding Paper (0 to 12) |
Fine Motor Integration
|
2 subtest components: Copying a Square (0 to 5) Copying a Star (0 to 5) |
Manual Dexterity |
1 subtest component: Transferring Pennies (0 to 20) |
Bilateral Coordination |
2 subtest components: Jumping in Place—Same Sides Synchronized (0 to 5) Tapping Feet and Fingers—Same Sides Synchronized (0 to 10) |
Balance |
2 subtest components: Walking Forward on a Line (0 to 6) Standing on One Leg on a Balance Beam—Eyes Open (0.0 to 10.0) |
Running Speed and Agility |
1 subtest component: One-Legged Stationary Hop (0 to 99) |
Upper-Limb Coordination |
2 subtest components: Dropping and Catching a Ball—Both Hands (0 to 5) Dribbling a Ball—Alternating Hands (0 to 10) |
Strength—[Knee] or [Full] Push-ups |
2 subtest components: a. Knee
Push-ups Sit-ups (0 to 99) |
Notes & Observations |
Examiner provided Notes & Observations for the Short Form. |