Speech/Language Teacher Checklist
Student Name: _________________________________
Grade: __________________
DOB:_________________
Teacher: ___________________________________
Articulation
The student mispronounces or leaves off sounds in words.
Use the chart below to rate how intelligible the student is to you.
Completely
Intelligible
__________
Highly Intelligible
Fairly Intelligible
Unintelligible
-Intelligibility depends on situation,
topic, etc.
-Parents and others have slight
difficulty understanding
-Intelligible only if topic known
-Consistent difficulty with
intelligibility with parents/others
-Almost never understood
in conversational speech
2
3
4
1
Receptive Language
The student does not comprehend grade-appropriate vocabulary.
The student has a difficult time following spoken directions.
The student has difficulty processing verbal information.
Voice
The student’s speaking voice is unusually:
LOUD
SOFT
(CIRCLE ONE)
The student has an unusual quality to his/her voice i.e. hoarseness, nasal, breathy.
Speech Rate and Fluency
The student frequently stutters when speaking.
The student uses excessive “um,” “uh”, “you know” “a”, etc. when speaking.
Pragmatic Language
The student does not use age-appropriate conversational skills i.e. turn-taking
asking/answering questions, staying on topic, initiating conversation.
The student does not interact in an age-appropriate manner with peers.
1
The student’s academic performance is below grade level and his/her speech or
language skills have a significant adverse affect on one or more of these areas:
(circle all that apply)
Speaking
Reading
Writing
Spelling
Math
Identify each area of impact and tell how the speech/language deficit affects
academic performance:
Area ________________
Impact ____________________________________
Area ________________
Impact ____________________________________
Area ________________
Impact ____________________________________
Area ________________
Impact ____________________________________
List the interventions you have used to assist the student and the outcome of each:
Intervention
Outcome
Please select one:
In my opinion, this student has a communication problem that adversely affects
educational progress in a significant way.
_______________________________________
Teacher
_________________
Date
In my opinion, this student does not have a communication problem that adversely
affects educational progress in a significant way.
_______________________________________
Teacher
_________________
Date
2