Spring Branch ISD
COMMUNICATION SAMPLE FORM
Student’s name:__Jane Smith__________________
ID number:____________________________
SLP: ______________________________________
Date of sample:_______9/14/10_________________
Contexts
__X___ Conversation
__X___ Classroom Interaction Observed during small group activity in science class.
_____ Interaction with peers ____________________________________________________________
__X __Structured Language Tasks retelling favorite movie “Mean Girls”___________________________
Topics/tasks
Topics: __Difficulty at school, after school activities (t.v.); science experiment (class)
_______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Tasks: retelling favorite movie without prompts/ then with
prompts__________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Identifies difficulty with speech/language
______Did not identify any difficulty with speech/language
Student’s comment(s) about speech/language difficulty: Doesn’t always understand what the teacher is talking
about. She asks questions but often still doesn’t understand.
General Pragmatic Skills
Generally Appropriate:
Difficulty noted:
_____ Maintained/initiated topics
_x__ Did not maintain/initiate/share topics
______Maintained appropriate turns
_x__ Required prompting to maintain or
______Provided clear info/adjusted to the listener
share topics and turns
______Follows social cues
____ Did not adjust to listener
______Able to revise
_x__ Did not revise
Examples: _________________________________
__________________________________________
__________________________________________
__________________________________________
Examples: Responded to questions and prompts, but
did not initiate. Couldn’t revise when message was
not clear. Vague vocabulary
___________________________________________
___________________________________________
___________________________________________
Generally Appropriate:
_____ Vocabulary for age/peers
______Organization-easy to follow
______Provided adequate information
______Appropriate sequence
Language Content
Difficulty noted:
_x__ Vague referents/limited vocabulary
_x__ Difficult to follow/frequent revisions
_x__ Inadequate information for listener
____ Difficulty with sequence
Examples:_________________________________
__________________________________________
__________________________________________
__________________________________________
Examples: (Can type specific sentence here
supporting your observations above.)
And when they were doing that stuff, they said trash
and stuff.
Language Structure
Generally Appropriate:
Weaknesses in language structure:
_____Sentence structure comparable for peers
___x__Simple sentence structure
_____Used a variety of sentence structures
______Grammatic errors noted
_____Elaborated sentence structure noted:
______Primarily _____-word sentences
______Noun phrases
______Reduced MLU for age (< 5 years)
______Conjoined sentences
______Elaborated clause structure
Examples: _________________________________
__________________________________________
Examples: _______________________________
__________________________________________
Articulation
__x__No errors noted
Additional errors noted:
_____Errors consistent w/ standardized assessment
_____Additional errors noted in spontaneous
speech
Phonological Processing
__n/a No phonological processing patterns noted
_____Phonological patterns are not typical for age
_____Phonological processing patterns noted
_____Phonological patterns are disordered/atypical
are appropriate for age (developmental)
Specify:____________________________________
Specify:___________________________________
___________________________________________
__________________________________________ ___________________________________________
__________________________________________ ___________________________________________
Intelligibility
__X_ Easily understood
_____Easily understood although errors noted
_____Intelligibility decreased in connected speech
_____Intelligibility decreased when context was not known
_____Intelligibility was estimated to be approximately ___________%
Stimulability
_n/a_ Student was stimulable for all errors noted.
_____Student was not stimulable for the following
____ Student was stimulable for phonemes which
errors: ___________________________________
are usually developed by his age.
_____Student was stimulable for the following
phonemes: ________________________________
Generally adequate:
__x__ Pitch
__x__ Loudness
_____ Prosody
__x__ Quality
Voice
Inadequacy noted:
_____Pitch
_____Loudness
_____Prosody
Explain:___________________________________
__________________________________________
__________________________________________
______Quality
Explain:___________________________________
__________________________________________
__________________________________________
Fluency
Difficulty noted:
_____Rate
_____Rhythm
(* Additional detailed assessment required)
Explain:___________________________________
Explain:____________________________________
__________________________________________ ___________________________________________
__________________________________________ ___________________________________________
__________________________________________ ___________________________________________
Generally appropriate:
_x___ Rate
__x__ Rhythm
Summary Statements
Functional speech/language skills appear to be
Weaknesses are noted in functional speech/language.
appropriate for age.
____This is consistent with/supports results of
standardized testing.
____Functional communication skills are
inconsistent with results of standardized testing.
__x_ These weaknesses are consistent with/support
results of standardized testing.
____ Functional communication skills are
inconsistent with results of standardized testing.
SAMPLE WRITE-UP
Informal Assessment Strategies
A communication sample was collected during conversation with the examiner, and was asked to retell the story
of her favorite movie “Mean Girls.” Jane was also observed during class interacting in a small group during
science.
During conversation, Jane discussed some difficulty she has at school, her favorite after school activities, and
the science experiment that she did in class. When asked if she had any difficulties with speech or language,
Jane indicated that she does not always understand what the teacher is talking about. She stated that she asks
questions but she often does not understand.
When asked to retell the story from her favorite movie, she was difficult to follow, even when given prompts.
During the communication sample tasks, difficulty was noted with pragmatic skills. Jane usually responded to
questions and prompts but she did not initiate any topics. She required prompting to maintain topics and turns.
For example, Jane stated in her narrative “And when they were doing that stuff, they said trash and stuff.”
When the examiner provided facial cues indicating she did not understand the meaning, Jane did not revise what
she said to make the meaning more clear.
Jane’s language content included limited vocabulary, and she was difficult to follow. She provided inadequate
information for the listener. Jane used primarily simple sentence structure.
No articulation errors were noted, and she was easily understood. Aspects of vocal pitch, loudness, prosody and
quality were adequate. Jane’s speech fluency was judged to be appropriate.
Weaknesses were noted in Jane’s functional speech/language in pragmatics, content and structure. These
weaknesses are consistent with results of standardized testing.