Screener & Checklist Builder

White Settlement ISD — APE Referral & Observation

4-level inputs (Often / Sometimes / Rarely / Not Observed) • Averages mapped to Proficient / Developing / At Risk (ignore 0)

Child's Name

School

Evaluator

Date of Assessment

Avg: 1.00

At Risk

Skill / Behavior	Often	Sometimes	Rarely	Not Observed
Performs activities requiring upper body strength (e.g., pushups, throwing, chest pass)
Performs activities requiring lower body strength (e.g., running, hopping, kicking)
Performs activities requiring flexibility (e.g., stretching, bending, tumbling)
Performs activities requiring endurance (e.g., mile run, endurance games)

Avg: 1.60

Developing

Skill / Behavior	Often	Sometimes	Rarely	Not Observed
Performs non-locomotor skills (e.g., twisting, turning, balance, bending)
Moves safely in environment (e.g., dodging, space awareness, directions)
Uses PE equipment (e.g., balls, bats, scooters)
Performs locomotor skills (e.g., running, jumping, galloping, hopping, skipping)
Performs manipulative skills (e.g., throwing, catching, kicking, striking)
Dance skills (e.g., rhythm, patterns, creative movement)
Plays low organized games (e.g., relays, tag, teacher-made games)
Sports skills (e.g., softball throw, soccer kick, volleyball serve, tennis hit)
Plays organized sports (e.g., basketball, soccer)

Additional Notes & Observations