ColleagueConsultationRequest Fillable .pdf
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OCCUPATIONAL THERAPY COLLEAGUE CONSULTATION
Prince George’s County Public Schools * Programs and Services * Occupational Therapy
John Carroll Building 1400 Nalley Terrace, Landover, Maryland 20785 * 240-696-3218
Please download this form then email a completed copy to your school’s assigned OT. You may also
email it to the OT office at Joanna.McGraw@pgcps.org.
Student number: __________________
☐ General Education
☐ Transitional Program
☐ Home and Hospital
Has an IEP:
Has a 504:
☐ yes ☐no (if yes, disability:_______)
☐ yes ☐no (if yes, disability:________)
Has a service plan: ☐yes ☐no ( if yes, disability:________)
Area (s) of Primary Concern:
☐ Fine motor/Written communication
☐ Mealtime participation/Self-care
☐ Social participation
☐ Managing materials
Please describe how the above concern is impacting this student’s participation in the
What data do you have to show the effectiveness/ineffectiveness of strategies that have been
implemented as part of the RTI process ?
If you need strategy ideas, please click on this link PGCPS CEIS/RTI Website Requests will not be
accepted without data.
Data (work samples,
Please share any other additional information:
Person Completing Form____________________________________Position________________
Phone number____________________________ Email___________________________
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