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School Readiness Form

(ISD SPED Form 1)


LAST NAME FIRSTNAME SURNAME

DATE OF BIRTH (MM/DD/YY) AGE SEX ADDRESS CONTACT NUMBER

DIAGNOSIS INTERVENTION GIVEN DATE OF FIRST SESSION DATE OF LAST SESSION


OT SP PT _________ (MM/YY) (MM/YY)

The following skills are pre-requisites for successful school placement. Kindly check () those that apply to the child:
Domain Pre-requisite Skills Remarks
Imitates actions.
1. Cognitive Recalls information with minimal assistance.
Matches identical objects.
Responds when name is called.
Follows commands with gestures or with
2. Language-
reference to PECS.
Communication
Communicates needs independently through
leading, pointing, gestures, PECs, or words.
Readily complies.
Sustains attention with minimal physical
prompting.
Exhibits joint attention.
Remains seated when appropriate.
3. Behavior Does not exhibit behavior that would distract
other students (i.e., tantrums, self-stimulation,
shouting, etc.)
Does not exhibit behavior that would jeopardize
the safety of others as well as their own (i.e. self-
abuse, aggression, etc.).
Holds writing instrument independently.
Colors within the paper.
Is mobile or is able to ambulate around the room
4. Motor
with or without support.
Is able to sit on chair independently or with
assistive devices.
Is toilet-trained.
5. Self-Help
Feeds self independently.

Recommendation:

The child is recommended for Special Education Assessment to verify school readiness and to determine
appropriate school placement and intervention. Kindly present this form to the SPED Program Coordinator.

Prepared by: Received by:


____________________________ ________________________________________
SPED Program Coordinator

To be accomplished by the Special Education Program Coordinator


DATE RECEIVED SCHEDULE OF SCHOOL READINESS FORM VERIFICATION SCHEDULE OF INITIAL IEP SCHEDULE OF CASE-
IMPLEMENTATION (1 MONTH) CONFERENCE

SCHEDULE OF CURRICULUM ASSESSMENT

ISD SPED Form 1


Revised: April 21, 2016
Revised: September 7, 2016
Revised: December 5, 2017