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CHARLES COUNTY PUBLIC SCHOOLS
DEPARTMENT OF SPECIAL EDUCATION
Speech (Voice) Eligibility Checklist
Name of Student:
School:
Date of Birth:
Date of Eligibility Determination:
☐Y ☐N 1.
Documentation by a speech-language pathologist of deviation from the norm in age and gender
in one or more of the parameters of voice:
Evaluation source/date:
☐Y ☐N 2.
Pitch (descriptors might include: shrill, guttural, etc.)
☐Y ☐N 3.
Quality (descriptors might include: breathy, hoarse, gravelly, nasal, denasal, etc.)
☐Y ☐N 4.
Volume (descriptors might include: soft, loud, etc.)
☐Y ☐N 5.
AND, Documentation is present that the voice deviation is not the result of temporary and/or
medical problems (e.g. normal voice change, allergies, colds, etc.)
AND
Documentation of Educational Impact Form and other documentation as needed such as informal testing,
speech samples, and other educational evidence supplied by the educator that demonstrates the adverse impact
of the voice disorder upon the student’s success in the educational setting in one or more of the areas listed
below. Examples of impact include:
☐Y ☐N 4. ACADEMIC IMPACT (ability to benefit from the curriculum) demonstrated by communication
problems that interfere with student’s ability to orally communicate and participate in class
discussions.
☐Y ☐N 5. SOCIAL IMPACT (ability to interact with peers and/or adults) demonstrated by communication
problems which interfere with the ability to be understood, difficulty
initiating/maintaining/terminating interactions, teasing by peers due to voice difficulties, or
observation of student demonstrating embarrassment and/or frustration regarding
communication problems.
☐Y ☐N 6. VOCATIONAL IMPACT (applicable to students who participate in vocational or job-related
activities) demonstrated by problems which interfere with the ability to be understood,
difficulty initiating/maintaining/terminating interactions, or observation of student
demonstrating embarrassment and/or frustration regarding communication problems.
The IEP team used the above interpretation of the evaluation data to determine:
☐ The student has a voice impairment which adversely impacts his/her education and
is eligible for specifically designed instruction and related services (IEP).
☐ The student has a voice impairment but it does not adversely impact his/her
education; therefore, the student is not eligible for an IEP.
☐ The student does not have a voice impairment and is not eligible for an IEP.
☐ Evaluation data was insufficient to determine eligibility. Additional assessments
and/or data will be obtained/collected in the area(s) of:
SE 07/13
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