Name of child:
Dob:
School:
Name of SENCo:
Year group:
Chronological age in years and months:
Date checklist completed:
Name of class teacher:

This checklist is to help identify children who are a cause for concern and may have speech, language and communication needs.

This form should be completed by someone who knows the child well.

Refer to www.speakupsalford.nhs.uk
for the developmental norms if needed.

To refer a child to the Learning Support Service please request a referral form from: LSSreferrals@salford.gov.uk
Has this child any other known difficulties? If so – please specify:
Is this child EAL? YES/NO If yes – what is the child’s home language?
Speech
Speech sounds are not clear.
Please tick as appropriate:
 = most of the time
 = some of the time
O = hardly ever/never
Has difficulties in making themselves understood by adults and/or other children.
Reduces multi-syllabic words e.g. potato – “tato”, banana – “nana”.
Stammers
For more information on stammering go to: www.stammering.org/
Additional comments:
Expressive language
Shows little interest in communication.
Uses language typical of a much younger child.
Has a limited range of vocabulary for his/her age.
Word-retrieval difficulties – has “tip of the tongue” moments.
Salford learning support service - SLCN

Uses related but incorrect word e.g. orange peas for baked beans or telescope for periscope.
Uses “general all purpose” verbs e.g. “he do the picture”.
Frequently hesitates before speaking.
Uses “filler” words such as: “thingy”, “whatsit”.
Misses whole words e.g.
“where book?” “I been shopping” “Sam naughty”.
Misses off word endings e.g. ing, ed, plurals etc.
Has difficulty retelling a story or relating news.
Only uses short, simple sentences.
Echoes sentences of others.
Uses language well for commentary but struggles with explanations.
Additional comments:
Receptive Language (Understanding)
Finds it difficult to listen - “switches off”.
Has difficulty following instructions and often needs them simplified.
Has a short attention span.
Responds inappropriately or misinterprets what has been said.
Watches others in order to know what to do.
Has difficulty understanding “wh” questions and responds incorrectly to them.
Has poor understanding of abstract concepts e.g. time – tomorrow, today etc.
Has difficulty understanding language of sequencing e.g. order of days of week, time connectives.
Has poorly developed interactive and imaginative play.
Literal interpretation e.g. “Pull your socks up”.
Additional comments:
Salford learning support service - SLCN

Has poor eye contact.
Social use of language
Finds it difficult to take turns.
Stands too close to others or lacks awareness of personal space.
Tends to talk about the same things over and over.
Interrupts inappropriately.
Has difficulty with making friends and joining in games.
Unsettled by changes of routine.
Echoes language of adults/peers.
Has difficulty reacting appropriately to emotion.
Uses language that appears to be more advanced than their age or understanding.
Struggles to understand verbal jokes – enjoys visual humour.
Additional comments:
Reminder:
Please refer to www.speakupsalford.nhs.uk
for advice on strategies, resources and developmental norms etc
Salford learning support service - SLCN