SAN ANTONIO INDEPENDENT SCHOOL DISTRICT COMPREHENSIVE INDIVIDUAL ASSESSMENT ARD Date ELIGIBILITY REPORT: SPEECH HANDICAPPED NAME SEX Page 1 of 8 Initial Assessment Re-evaluation Additional Assessment Other: SCHOOL DOB CA ID # REFERRAL DATE GRADE SS # EVALUATION DATE REPORT DATE BACKGROUND INFORMATION RECEIVED IN ELIGIBILITY FOLDER INCLUDES: 1. Handicapping condition(s) Other: 2. Past history of therapy information 3. Past special education services 4. Attendance YES NO Assessment of this student was conducted using standard assessment procedure for all tests administered. If no, explain rationale: LANGUAGE (COMMUNICATION STATUS) Sources of Data (formal and informal measures) Assessment Dates RESULTS AND INTERPRETATIONS: Student’s dominant language: English Spanish Student’s level of proficiency: English Receptive Expressive Receptive Average Below Average LPAC information: Test: Results/Score: This student is limited English proficient. YES NO LPAC recommendations: Revised 02/18/16 Assessment Dates Student expresses himself/herself best: Orally Other method of communication Specify, including basis for determination: Other language: Above Average Sources of Data (formal and informal measures) Expressive Based on the assessment of this student’s language abilities, the remainder of the assessment was conducted in: English Combination: Bilingual assessor conducted the assessment Interpreter was used. Specify language or mode of of communication: Other language, specify: Page 2 of 8 Name DOB PHYSICAL (INCLUDING MOTOR ABILITIES) Sources of Data (formal and informal measures) Assessment Dates Sources of Data (formal and informal measures) Assessment Dates RESULTS AND INTERPRETATIONS: VISION: within normal limits without glasses with glasses not within normal limits (See report from ophthalmologist or optometrist) medical referral sent HEARING: within normal limits unaided aided not within normal limits (See report from otologist or audiologist) medical referral sent HEALTH HISTORY: Significant health history. If yes, specify: YES NO YES NO YES NO This student appears to have one or more physical conditions which directly affect his/her ability to profit from the educational process. If yes, specify: Adapted physical education is indicated. If yes, attach a separate assessment report for adapted physical education. SOCIOLOGICAL Sources of Data (formal and informal measures) Assessment Dates RESULTS AND INTERPRETATIONS: CULTURAL, LINGUISTIC, AND EXPERIENTAL BACKGROUND Comes from non-English speaking home or geographic area Home and school expectations are incongruent Recent immigrant High family mobility or migrant Sources of Data (formal and informal measures) Assessment Dates Displays heightened stress in cross-cultural interactions Limited or sporadic school attendance Few readiness skills Other:_________________________________________ CULTURE AND/OR LIFESTYLE FACTORS influence this student’s learning and behavioral patterns. If yes, explain: YES NO YES NO This student’s sociological status indicates a LACK OF PREVIOUS EDUCATIONAL OPPORTUNITIES. If yes, explain: Revised 02/18/16 Page 3 of 8 Name DOB EMOTIONAL Sources of Data (formal and informal measures) Assessment Dates Sources of Data (formal and informal measures) Assessment Dates Sources of Data (formal and informal measures) Assessment Dates RESULTS AND INTERPRETATIONS: INTELLIGENCE AND ADAPTIVE BEHAVIOR Sources of Data (formal and informal measures) Assessment Dates RESULTS AND INTERPRETATIONS: Intellectual functioning was assessed using: Describe pertinent findings: formal measures informal measures Adaptive behavior was assessed using: Describe pertinent findings: formal measures informal measures The student’s level of intellectual functioning is consistent with his/her adaptive behavior. If no, explain: YES NO ACADEMIC PERFORMANCE Sources of Data (formal and informal measures) Assessment Dates Sources of Data (formal and informal measures) Assessment Dates RESULTS AND INTERPRETATIONS: ACADEMIC FACTORS Referral information verifies that student’s current academic progress is on grade level; and not on grade level; and can profit or speech/language therapy intervention. Revised 02/18/16 satisfactory not satisfactory; and that he/she is can not profit from classroom instruction without Page 4 of 8 Name DOB ORAL PERIPHERAL DATE lips teeth diadochokinetic rate velum Results: Within normal limits INTERPRETATIONS/COMMENTS: YES hard palate soft palate pharynx tongue other NO TESTING INFORMATION LANGUAGE Date Sources of Data Scores INTERPRETATION/BEHAVIORAL OBSERVATIONS Age appropriate YES NO Compared to peers, the student: attends to spoken language comprehends single-word meanings understands “WH” questions follows oral directions understands figurative language, verbal humor, sarcasm Results: Within normal limits YES INTERPRETATIONS/COMMENTS: Revised 02/18/16 demonstrates adequate work knowledge (expressive, vocabulary) demonstrates appropriate grammar/morphology uses appropriate sentence length and complexity responds appropriately to “WH” questions uses language to express a variety of communication intents carries on a conversation appropriately NO Page 5 of 8 Name DOB PRAGMATICS Date Sources of Data Age appropriate YES NO greeting & farewell calls for attention request permission request clarification request for action protesting Results: Within normal limits INTERPRETATIONS/COMMENTS: predicting maintaining topic turn taking yes/no questions “WH” questions YES NO ARTICULATION Date Sources of Data Severity ____ mild ____ moderate ____ severe INTERPRETATION/BEHAVIORAL OBSERVATIONS Within normal limits YES NO speech intelligibility in single words speech intelligibility in conversation sound stimulability developmentally appropriate speech dialectical Results: Within normal limits Substitutions: Omissions: Distortions: Dialectical: Phonological Features: Revised 02/18/16 YES NO Page 6 of 8 Name DOB FLUENCY Date Sources of Data Scores Indicate behaviors present below: aware of stuttering avoids certain speaking situations talks freely despite stuttering behavior fluent with certain listeners/social greetings sound/syllable/word/phrase repetitions (circle one) prolongation’s blocks rate of speech-rapid/slow/arrhythmic (circle one) secondary features _____________________________________________________________ Results: Within normal limits INTERPRETATIONS/COMMENTS: YES NO VOICE Date Sources of Data Indicate abnormal features below: VOCAL QUALITY aphonic breathy harsh hypernasal vocal fry glottal attack other Results: Within normal limits INTERPRETATIONS/COMMENTS: Revised 02/18/16 VOCAL PITCH too high too low monotone pitch break other YES NO VOCAL INTENSITY too loud too soft Date medical referral sent: Medical statement and/or recommendations: Page 7 of 8 Name DOB AUGMENTATIVE/ALTERNATIVE COMMUNICATION Based on testing information, this student’s mode of communication is oral Sources of Data (formal and informal measures) Assessment Dates YES NO Sources of Data (formal and informal measures) If no, specify: Assessment Dates Augmentative/Alternative Communication (AAC) needs were considered. Based on the previously addressed competencies: The AAC devices/services needed to provide appropriate special education, related services, or supplementary aids and services: include: are addressed in the modifications sections of this report. are addressed in the attached report. other: AAC devices/services are not recommended at this time. INTERPRETATIONS/COMMENTS: LEARNING COMPETENCIES DISORDER ARTICULATION RECEPTIVE LANGUAGE EXPRESSIVE LANGUAGE FLUENCY VOICE Revised 02/18/16 SPECIFIC STRENGTH SPECIFIC WEAKNESSES AREAS TO BE ADDRESSED Page 8 of 8 Name DOB STATEMENT OF ELIGIBILITY: The student has a communication disorder which adversely affects his/her educational performance. YES NO mild moderate severe profound language YES NO articulation mild moderate severe profound YES NO fluency mild moderate severe profound YES NO voice mild moderate severe profound YES NO auditory processing mild moderate severe profound FUNCTIONAL IMPLICATIONS FOR THE EDUCATIONAL PROCESS YES NO Based on the identified speech and language deficit, this student will exhibit difficulty in mastering the essential elements at the appropriate grade level of listening, speaking, and/or oral usage. ASSURANCES The multidisciplinary team assures that the testing, evaluation materials and procedures used for the purposes of evaluation were selected and administered so as not to be racially or culturally discriminatory. The multidisciplinary team assures that the tests and other evaluation materials have been validated for the specific purpose for which they were used. The multidisciplinary team assures that the tests and other evaluation materials were administered by trained personnel in conformance with the instructions provided by their producers. RECOMMENDATIONS enroll in speech therapy continue speech therapy dismiss from therapy Student’s needs will be met by re-evaluate at a later date further testing recommended other (PPCD, etc.) direct, consultation, and/or classroom inclusion services. Signature of Evaluator Position Date Signature of Evaluator Position Date Revised 02/18/16