Speech & Language Concern Checklist
Return to PSM/CTARS along with PSM Worksheet #1
Student
Teacher
Date form completed
Check areas of concern
Speech Production Concerns *(also complete “Articulation Screener” form)
 Student has difficulty producing individual speech sounds, and this significantly
interferes with communication. Sounds in words may be omitted, distorted, or substituted
with other sounds.
 Student has conversational speech that is not understandable (intelligible) all or some of
the time and that significantly interferes with communication.
 Other (please specify):
Expressive Language Concerns
 Student does not talk in complete sentences and this significantly interferes with
communication. – Instead, the student talks mostly in incomplete phrases and sentences.
 Student’s sentences contain numerous grammar errors that are not typical for students of
the same age and that significantly interfere with communication (e.g., plurals, negatives,
verb tenses, pronouns). This may NOT apply to students who are English Language
Learners or who are known to speak a dialect of English.
 Student has difficulty providing explanations or directions that make sense to the listener.
 Student retells stories or personal narratives that are disorganized, incomplete, or hard to
follow.
 Student has difficulty in conversation that significantly interferes with communication
(e.g., does not take turns or switches topics inappropriately).
 Other (please specify):
Receptive Language/Comprehension Concerns
 Student does not appear to understand/follow an age-appropriate direction that contains
multiple parts.
 Student does not appear to understand teacher questions presented in class that are ageappropriate.
 Student does not appear to understand vocabulary words used in class that are at the
student’s independent/instructional reading level.
 Student does not request clarification when it appears the student does not understand a
teacher’s verbal direction.
 Student does not appear to understand comprehension questions about a short story that is
at the student’s independent/instructional reading level.
 Other (please specify):
Speech Fluency Concerns
 Student’s speech contains disfluencies that significantly interfere with communication.
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Sound, syllable, or word repetitions with obvious tension in face or neck muscles
Sound prolongations
Blocks (no sound or airflow)
Student appears frustrated or upset about his/her dysfluent speech pattern.
Other (please specify):
Voice Quality Concerns
 Student’s voice quality significantly interferes with communication
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Harsh or hoarse voice quality
No voice
Excessively nasal voice quality
Other (please specify):
Articulation Screener
Return to PSM/CTARS with PSM Worksheet # and Speech-Language Concern Checklist
A. Teacher says:
Student says: (write response phonetically)
1. boats
2. fork
3. glasses
4. gum
5. leaf
6. nose
7. rock
8. soap
9. spoon
10. star
11. watch
12. chip
13. zipper
14. block
15. grade
16. fruit
B. On average, I understand about X % of the student’s speech when he/she talks to me in
the classroom:
0-30%
40-50%
60-70%
80-90%
Speech-Language Classroom Intervention Plan
Complete at initial and follow-up PSM/CTARS team meetings
Student
Teacher
Intervention Start Date
Desired Outcomes/Goals (relate to specific speech-language behaviors/concerns identified on
PSM worksheet #1 and Speech-Language Concern checklist):
Planned Classroom Interventions (List and prioritize):
-----------------------------------------------------------------Intervention Completion Date
Results of Interventions/Follow-up:
Prereferral Documentation for Language, Voice, Fluency Concerns
Use a separate form for each intervention – 2 interventions are required
Student:
Intervention Start Date:
Teacher:
Intervention:
Teacher Support:
Student response:
1 – no change
FS – full support
Week 1
Monday
2
Tuesday
PS – partial support
3 – some positive change
Wednesday
Thursday
4
MS – minimal support
5 – good positive change
Friday
Teacher
Support
Student Response
Week 2
Teacher
Support
Student Response
Week 3
Teacher
Support
Student Response
Week 4
Teacher
Support
Student Response
Week 5
Teacher
Support
Student Response
Week 6
Teacher
Support
Student Response
Return this sheet to PSM/CTARS Team at follow-up meeting.
Comments
Prereferral Documentation for Articulation Concerns
Use a separate form for each intervention – 2 interventions are required
Student:
Intervention Start Date:
Teacher:
Intervention:
Stimulus:
Student response:
Week 1
I – sound in isolation
1 – unable to produce sound
Monday
Tuesday
SS – sound in syllable
SN – sound in sentence
2 – inconsistently produces sound
3 – easily produces sound
Wednesday
Thursday
Friday
Comments
Stimulus
Student Response
Week 2
Stimulus
Student Response
Week 3
Stimulus
Student Response
Week 4
Stimulus
Student Response
Week 5
Stimulus
Student Response
Week 6
Stimulus
Student Response
Note: It is recommended that the sound be targeted in isolation for weeks 1 and 2, targeted in syllables for weeks 3 and 4, and targeted in
sentences for weeks 5 and 6.
Return this sheet to PSM/CTARS Team at follow-up meeting.