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SECTION 1 — OCCUPATIONAL THERAPIST INFORMATION

SECTION 2 — STUDENT / CLASSROOM CONTEXT

Is this request for?
One Student
Multiple Students
Classroom-Wide Consideration
Other
School Setting
Elementary
Middle School
High School
Specialized Program
Single choice
Yes
No
Not Yet
Is Caregiver Consent Available or Being Pursued?
Yes
No
Being Pursued
Not Applicable at this Stage

SECTION 3 — CURRENT ENVIRONMENTAL / CLASSROOM CONCERNS

Which Routines or Transitions are Most Affected?
What Classroom Impacts are Currently Being Observed?
How Often are These Concerns Occurring?
Multiple Times Daily
Daily
Several Times Per Week
Weekly
Occasionally
Varies Significantly

SECTION 4 — STRATEGIES ALREADY TRIED

What Strategies Have Already Been Tried?

SECTION 5 — TRIAL GOALS

What Would You Hope a Classroom zPod Trial Would Support?

SECTION 6 — BEFORE & AFTER EVALUATION

Which Before-and-After Outcomes Could Your Team Help Track?
Who Would Be Involved in Providing Feedback?

SECTION 7 — TRIAL READINESS

Is There a Defined Space Where a Classroom zPod Could Be Placed?
Yes
No
Unsure
Is the School Open to a Structured Trial Period with Before-and-After Feedback?
Yes
No
Unsure
Preferred Timeline for Trial Discussion
As Soon As Possible
Within 1 Month
Within 3 Months
Planning for Next School Year
Unsure

SECTION 8 — ADDITIONAL INFORMATION

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