Multidisciplinary Team Evaluation Report Form Language Impaired
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1South Bend Community School Corporation
Special Education Services
Multidisciplinary Team Evaluation Report-- Language Impaired
Date of the Evaluation:_____________
Purpose of evaluation:
Initial Eligibility
Re-evaluation
Student_________________________________ School__________________________________________
ID#__________________
STN________________________ DOB: ____________________________
Student was 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___
No___
Members of the Multidisciplinary Team: Speech-language Pathologist:______________________________
Classroom Teacher:____________________Parent/guardian:___________________Other:_______________
Component
Test(s)
Results
Word retrieval
Phonology
Morphology
Syntax
Semantics
Pragmatics
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 language impairment may have had on this student’s achievement test results and/or
academic and/or functional performance; describe interventions used:____________________________________
___________________________________________________________________________________________
Medical information educationally relevant to language impairment:______________________________________
___________________________________________________________________________________________
Exclusionary factors: (√ if applicable)
____Sole reason for referral is student’s native language is not English.
____Student is deaf or hard of hearing or has a specific learning disability with language deficits or auditory
processing difficulties and is not eligible for services solely for language impairment. Based on the results of this
___evaluation ___ re-evaluation, this student 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
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