Appendix 4.

A
•
Activity Analysis Form

Part 1: Introduction

Description of the activity:

Sequence (steps) of activity:

1.
2.
3.
etc.

Timing needed to complete or perform individual steps:

Objects, materials, and their properties:

Physical environment (space demands):

Safety precautions and contraindications:

Social environment:

Personal contextual and client factors:

• Personal (age, gender, socioeconomic, education)

• Client factors (values, beliefs, spirituality)

Note. This form was created by the authors and Jim Hinojosa.
Consider the relevance and meaningfulness of the activity that influence
performance:

• Current

• Past

• Future

Cultural, temporal, and virtual conditions within and around the client that
influence performance:

• Cultural

• Temporal (time):

• Virtual

Part 2: Activity Analysis Outline

R equired Actions and Performance Skills

Learning and Applying Knowledge (Sensory–Perceptual Skills)

ACTIVITY REQUIRES YES NO FOCUS ON

Watching Visual reception, sensory processing
Listening Auditory, sensory processing
Other purposeful sensing Tactile, proprioceptive, vestibular,
olfactory, gustatory, sensory
processing

Sensory processing—Internal mechanism used by the person to process and

respond to sensory input
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Note. Refer to the “Levels of Influence” definitions on page 82 of this text.

Visual reception—Interpreting stimuli through the eyes, including peripheral
vision, acuity, and awareness of color and pattern
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Auditory—Interpreting and localizing sounds and discriminating among

background sounds
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Tactile—Interpreting light touch, pressure, temperature, pain, and vibration

through skin contact or receptor
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Proprioceptive—Interpreting stimuli originating in muscles, joints, and other

internal tissues that give information about the position of one body part in
relation to another
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.
Vestibular input—Interpreting stimuli from the inner ear receptor regarding head
position
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Olfactory—Interpreting odors
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Gustatory—Interpreting tastes
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Basic Learning

ACTIVITY REQUIRES YES NO FOCUS ON

Copying Recognition, form constancy, spatial
relations, position in space
Rehearsing Sequencing

Recognition—Ability to identify familiar faces, objects, and other previously

presented material
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.
Form constancy—Recognizing forms and objects as the same in various
environments, positions, and sizes
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Spatial relations—Determining the position of objects relative to each other

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Position in space—Determining the spatial relationship of figures and objects to

self and other forms and objects
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Sequencing—Placing information, concepts, and actions in order

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Acquiring Skills

ACTIVITY REQUIRES YES NO FOCUS ON

Basic skills Motor control, praxis, body scheme,
Complex skills fine motor, crossing midline,
right–left discrimination, laterality,
bilateral integration, visual–motor
integration
Applying knowledge Level of arousal, orientation,
attention span
Thinking Memory, categorization, spatial
orientation, generalization, concept
formation
Solving problems—simple Learning, memory
Solving problems—complex
Making decisions Memory, concept formation,
categorization, generalization

Level of arousal—Demonstrating alertness and responsiveness to environmental

stimuli
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Orientation—The ability to identify person, place, time, and situation

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Sensory modulation—The ability to generate responses that are appropriately

graded in relation to incoming sensory stimuli
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Attention span—Focusing on a task over time

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.
Motor control—The use of functional and versatile movement patterns
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Praxis—Conceiving and planning a new motor act in response to an

environmental demand
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Body scheme—An internal awareness of the body and the relationship of body
parts to each other
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Ocular motor—Ability to move eyes to focus and follow objects

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Oral motor—Use of muscles in and around the mouth

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.
Fine motor coordination and dexterity—Using small muscle groups for
controlled movements, particularly in-hand object manipulation
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Visual–motor integration—Coordinating the interaction of information from the

eyes and body movement
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Crossing the midline—Moving the limbs and eyes across midline sagittal plane
of the body
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Right–left discrimination—Differentiating one side from the other

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Laterality—The use of a preferred or dominant hand or foot

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.
Bilateral integration—Coordinating both sides of the body
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Memory—Recoding information after a brief or long period of time

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Categorization—Identifying similarities and differences among pieces of

environmental information
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Concept formation—Involves organizing a variety of information to form

thoughts and ideas
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Spatial operations—Mentally manipulating the position of objects in various

relationships
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.
Learning—Acquiring new concepts and behaviors
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Generalization—Applying previously learned concepts and behaviors to a variety

of new situations
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

General Activity Demands

ACTIVITY REQUIRES YES NO FOCUS ON

Simple task Initiation of activity, time
Complex task management, termination of
activity, coping skills, self-
Multiple tasks control
Independent performance
Group performance Social conduct, interpersonal
skills

Initiation of activity—Starting a physical or mental activity

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Time management—The person’s ability to manage parcels of time as they relate

to the performance of tasks or activities
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.
Termination of activity—Stopping an activity at an appropriate time
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Coping skills—Identifying and managing stress-related factors such as anger,

disappointment, or frustration
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Self-control—Modifying one’s own behavior in response to environmental needs,

demands, constraints, personal aspirations, and feedback from others
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Social conduct—Involves interacting by using manners, personal space, eye

contact, gestures, active listening, and self-expression appropriate to the situation
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Interpersonal skills—Involves using verbal and nonverbal communication skills

appropriately
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.
Mobility

Postural alignment—Maintaining biomechanical integrity among body parts

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Postural control—Using righting and equilibrium reactions to maintain balance

during functional movements
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Depth perception—Involves determining the relative distance between objects,

figures, or landmarks and the observer and changes in planes and surfaces
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Body strength—Degree of gross muscle power when body movement is resisted

or is against gravity
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Carrying, Moving, and Handling Objects

Range of motion—Moving body parts through an arc of motion

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.
Extremity strength—Grade of muscle strength when body movement is resisted
or is against gravity
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Endurance—Sustained cardiac, pulmonary, and musculoskeletal exertion over

time
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Stereognosis—Identifying objects through proprioception, cognition, and sense

of touch
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Kinesthesia—Identifying the excursion and direction of movement

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Grasp patterns—Identifying the type(s) of grasp required to perform the activity

Level of Influence Observations:
 0
 1.
 2.
 3.
 4.
 Prehension patterns—Identifying the type(s) of pinch required to perform this
activity
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Fine motor—Ability to use small hand muscles and joints to perform refined
actions
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Figure–ground perception—Differentiating between foreground and background

forms and objects
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Topographical orientation—Determining the location of objects and settings and

the route to the location
Level of Influence Observations:
 0
 1.
 2.
 3.
 4.

Part 3: Summary

Once you have completed the activity analyses, consider the following:

1. Is the activity part of the client’s habits, routines, or rituals?

• Habits
• Routines
• Rituals
2. How does this activity relate to the client’s roles?
• Past
• Present
• Future

3. Does the activity facilitate self-expression or enhance self-concept?