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