Multidisciplinary Team Evaluation Report Speech Impaired

South Bend Community School Corporation

Special Education Services

Multidisciplinary Team Evaluation Report

Speech Impaired – Voice

Date of the Evaluation: _________________________________ Purpose:

£

Initial Eligibility

£

Re-evaluation

Student____________________________________ ID#: __________________ STN#: _____________________

School___________________________ Referred by:

£

Parent

£

Teacher ___ Other (Specify_______________)

Student has:

£

Normal hearing

£

Hearing loss

£

Referred for audiological follow up

£

Student uses assistive or augmentative technology for communication? Yes

If yes, what type?

___________________________________________________________________________________________

Members of the Multidisciplinary Team:

Speech-language Pathologist (SLP):_______________________Classroom Teacher:_______________________

Other:_______________________________ Parent/Guardian:_________________________________________

VOICE ASSESSMENT ADMINISTERED:__________________________________________________________

£

Pitch:

£

normal

£

too low

£

too high

£

pitch breaks

£

limited variability

£

Loudness:

£

normal

£

too loud

£

limited variability

£

Quality:

£

normal

£

hoarse

£

breathy

£

harsh

£

shrill

£

strident

£

variable

£

Nasal Resonance:

normal

denasal

hypernasal

£

Oral Resonance:

£

normal

£

lack of

£

excessive

Other characteristics: __________________________________________________________________________

Parent’s observations/comments summary (attach social and developmental history):________________________

___________________________________________________________________________________________

Teacher’s observations/comments summary (attach classroom teacher’s report):___________________________

___________________________________________________________________________________________

SLP’s observations/comments:___________________________________________________________________

___________________________________________________________________________________________

Oral examination results:________________________________________________________________________

Achievement test results (see classroom teacher’s report). ISTEP, NWEA, Brigance, curriculum-based

assessment, etc. Date(s) administered and results:___________________________________________________

___________________________________________________________________________________________

Comments on any effect the speech impairment may have had on this student’s achievement test results and/or

academic and/or functional performance:___________________________________________________________

___________________________________________________________________________________________

Medical information educationally relevant to speech impairment:________________________________________

___________________________________________________________________________________________

£

(√ if applicable)

Organic basis suspected for speech impairment; physician’s report attached.

Exclusionary factors: (√ if applicable or N/A if not applicable:

£

Speech impairment appears to be maturational in nature

£

Sole reason for referral is student’s native language is not English.

Based on the results of this

£

evaluation

£

re-evaluation, this student to appears to be

£

eligible

£

not eligible

for special education and related services. However eligibility is determined by the case conference committee.

_______________________________________

Speech-language Pathologist

8/18/12

Multidisciplinary Team Evaluation Report Speech Impaired - Voice

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