Speech/language Impairment Team Report Form Page 2
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25.
SOCIAL (PRAGMATIC) COMMUNICATION DISORDER –
Documentation which meets the following:
Yes
No
Assessment measures included norm referenced tests, multiple observations, checklists
•
and structured tasks.
Assessment procedures were used that are contextually based and involved multiple
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•
settings and communication partners.
Assessment results indicated deficits in functional limitations in effective communication,
•
social participation, social relationships, academic achievement, and/or occupational
performance, individually or in combination.
Assessment results have eliminated the presence of restricted repetitive behaviors,
•
interests, and other activities related to the diagnosis of Autism.
VOICE DISORDER – Documentation which meets the following:
6.
The student has a voice production rating of moderate or severe on the Voice Rating
•
Yes
No
Scale.
The existence or absence of a structural or functional pathology has been verified by an
•
otolaryngologist.
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SPECIAL CONSIDERATIONS:
7.
Lack of discrepancy between cognitive level and communication performance was not the
•
Yes
No
sole factor when determining eligibility for a severely speech and language disordered
student.
Eligibility for speech and language services was not determined on the basis of having a
•
primary language other than English or a language difference.
Yes
No
If verbal communication was not an effective means of communication for this student, an
•
augmentative/alternative communication evaluation was conducted to determine the need
Yes
No
for an alternative means of communication.
Yes
No
The student’s disability adversely affects educational performance.
8.
Yes
No
The student needs special education.
9.
The symptoms of this communication disorder as the primary disability are not attributable to
Yes
No
10.
hearing or other impairments that are more appropriately defined under another eligibility
category.
11.
Note educationally relevant medical findings, if any. (Write N/A if no relevant medical findings apply):
The
Eligibility Committee used the above evaluation data analysis and discussion to determine:
The student DOES meet the eligibility criteria for speech/language impairment that adversely impacts his/her
education and is eligible for special education and related services.
The student DOES NOT meet the eligibility criteria for speech/language impairment and is not eligible for special
education and related services as a student with speech/language impairment.
Eligibility Committee Members
Signature
Position
_____________________________________________
Chairperson
_____________________________________________
Evaluator/Specialist
_____________________________________________
Teacher
_____________________________________________
Parent
_____________________________________________
Student
_____________________________________________
Other
NOTE: If this report does not represent an individual team member’s conclusions, that team member
must submit a separate statement presenting the member’s conclusions.
Meeting Notes (if applicable)
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