Fillable Speech/language Impairment Team Report Form printable pdf download

Speech/Language Impairment Team Report

Hancock County

Student’s Full Name ______________________________

Date ________________________

School

________________________________________

Date of Birth ___________________

Parent(s)/Guardian(s)

____________________________

Grade _______________________

Address ________________________________________

WVEIS# ______________________

City/State _______________________________________

Telephone ____________________

Initial

Re-Evaluation

Other _____________

When considering whether or not a student may be eligible for special education and related services as a student with a

Speech/Language Impairment

, the Eligibility Committee must respond to each item below. The EC must answer “yes”, “no” or

“does not apply” (DNA) for each statement to appropriately conclude that the student meets the specific criteria as a student

with a Speech/Language Impairment.

The student’s multidisciplinary evaluation was sufficiently comprehensive to identify the student’s

special education and related services needs and administered in accordance with evaluation

Yes

procedures specified in WV Policy 2419, Chapter 3, Section 4.

LANGUAGE DISORDER – Documentation which meets the following:

Two or more procedures, at least one of which yields a standard score, were used to assess

•

Yes

both expressive and receptive modalities.

Language abilities are substantially and quantifiably below those expected for the student’s

•

chronological age and cognitive state of development, resulting in functional limitation in

DNA

effective communication, social participation, academic achievement or occupational

performance, individually or in any combination.

Norm referenced language tests were administered which yield two subtest or total test scores

•

with the following characteristics;

1.5 or more standard deviations (SD) below the mean;

a language quotient/standard score of 78 (mean of 100);

a stanine of two and/or a percentile of 8.

Non-standardized/informal assessment indicates that the student has difficulty understanding

and/or expressing ideas and/or concepts to such a degree that it interferes with the student’s

social/educational progress.

SPEECH SOUND DISORDER - Documentation which meets the following:

Yes

At least two procedures were used to assess the student, one of which is a standardized

•

measure.

The student’s speech has a negative impact on academic, social and/or vocational functioning,

•

DNA

and one of the following characteristics exists:

Two or more phonemic errors not expected at the student’s current age or developmental

–

level were observed during direct testing and/or conversational speech; or

Two or more phonological processes not expected at the student’s current age or

–

developmental level were observed during direct testing and/or in conversational speech.

PRESCHOOL: The student’s speech has a negative impact on social-communicative interactions

•

and one of the following characteristics:

Multiple phonemic errors that significantly reduce the student’s speech intelligibility and

–

are not expected at the student’s current age or developmental level were observed during

direct testing and/or conversational speech.

Two or more phonological processes that significantly reduce the student’s speech

–

intelligibility and are not expected at the student’s current age or developmental level

were observed during direct testing and/or in conversational speech;

CHILDHOOD-ONSET FLUENCY DISORDER (STUTTERING) - Documentation which meets the

following:

Yes

Disturbances in the normal fluency and time patterning of speech were observed that are

•

inappropriate for the individual’s age and language skills, persist overtime and are

characterized by frequent and marked occurrences of one (or more) of the characteristics

DNA

listed in the diagnostic criteria in Policy 2419.

The disorder causes anxiety about speaking or limitations in effective communication,

•

social participation, or academic or occupational performance, individually or in any

combination.

The student has a fluency rating of moderate or severe on the Fluency Communication

•

Rating Scale.

Speech/language Impairment Team Report Form

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