Name
Date
School District
Address
Multi- Disciplinary Report/ Speech and Language Report
CONFIDENTIAL
This report contains confidential information and is the property of School District.
Name:
Date of Birth:
Chronological Age:
Gender:
Ethnicity:
Grade:
Parents:
Address:
Home Phone:
Work Phone:
Primary Language:
EL:
School:
Date of Report:
Assessor:
CELDT Level:
CONFIDENTIALITY: The following assessment report may contain sensitive information
subject to misinterpretation by untrained individuals. Nonconsensual disclosure by unauthorized
individuals is prohibited by both the California State Education Code and the Welfare and
Institutions Code.
REASON FOR REFERRAL:
Include information about the source of referral, description of presenting behaviors, and major
reason the student was referred. Include information provided by the parent, teacher and student,
if applicable. List areas of suspected disability.
Example:
“STUDENT was referred for evaluation by X due to concerns in the areas of X. Parent
expressed concerns with X. Teacher has observed difficulties with X. Based upon the
referral information and review of school records, areas of suspected disability include
X, X, and X”.
EVALUATION PROCEDURES:
The assessment included all the components of a comprehensive evaluation required by state
regulations, including information provided by STUDENT’S parents or primary caregiver (if the
student is younger than 18 years of age). Information regarding STUDENT’S current classroom
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Date
performance (observations and assessments), and the observations of his/her teachers and other
providers of instructional or educational services were also included. STUDENT’S primary
language, racial, and ethnic background were considered prior to selection and interpretation of
evaluation procedures and measures and were administered by qualified personnel. All
assessment procedures measure a limited sample of a person’s total repertoire. The selected
measures should only be interpreted within the limits of their measured validity.
The following procedures were components of the evaluation:
PROCEDURES/ASSESSMENTS
DATE
BACKGROUND INFORMATION:
HEALTH AND DEVELOPMENTAL HISTORY:
Provide detailed information about developmental milestones, including language and
communication. Indicate how you obtained this information (was it through record review,
developmental questionnaire, parent interview?)
Include any health issues that might impact learning (i.e. frequent ear infections, seizures, cleft
palate, oral motor issues, etc)
Include information about past vision and hearing screenings, if remarkable, as well as current
hearing and vision screening results.
Example:
“On DATE, STUDENT’S vision and hearing were screened by the district nurse. Vision
screening results were/were not within normal limits. Hearing results were/we not within
normal limits. (If applicable) STUDENT uses X for amplification and wore X during
the assessments. (If applicable) STUDENT wears prescription glasses and wore them
during the assessments. STUDENT has/does not have adequate vision and hearing for
academic functioning. STUDENT does/does not require any accommodations be made
for his/her vision or hearing.”
FAMILY HISTORY:
Include information about who the child lives with (biological parents, adoptive parents, foster
parents, grandparents, relatives). If the child does not live with biological parents, indicate who
holds educational rights.
LANGUAGE:
Indicate the primary language of the home. If the student is an English Learner, include the most
recent CELDT scores. Best practice is to conduct a bilingual assessment for any student who is
at Beginning, Early Intermediate or Intermediate level. You may also need to consider a
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Name
Date
bilingual assessment for students at Early Advanced level is you believe second language may
still be an issue.
EDUCATIONAL HISTORY:
Include information about number of schools attended, daily school attendance, information
from report cards, teacher comments, IEP records, and discipline records. Document student
strengths and weaknesses, history of difficulties, and state test scores.
PREVIOUS ASSESSMENTS:
A thorough record review should be conducted prior to sending out an assessment plan. This
will help you determine what areas need to be assessed. You must always assess in all areas of
suspected disability for every assessment. If a parent or teacher continues to express concern
about something, (i.e. dysfluency), you must assess in this area even if it was ruled out at the last
assessment.
Include name of assessment, date it was administered and scores.
INTERVIEWS
Include detailed interview information gathered from the parent(s) or caregivers if the student
does not reside with his or her biological parents. Interview questions should focus on the
student’s language and communication. See semi- structured interview questions. The interview
process is also an opportunity to identify other possible areas of suspected disability.
Example:
“Parent was interviewed by the SLP on DATE. According to the parent, STUDENT is
able to communicate needs by X. When he becomes frustrated, STUDENT has difficulty
expressing his thoughts/emotions which results in X behavior. Student has difficulty
following directions, for example X”.
BEHAVIORAL OBSERVATIONS:
Observations should be conducted in:
 Classroom
 Unstructured environments
 During Testing
Example:
“STUDENT was observed in the classroom on DATE during language arts time.
He/she was observed to X. STUDENT was able to follow _ step directions. Student
participated in classroom discussion and appeared X.
Student was observed during recess on DATE. STUDENT’S interaction with peers was
X. STUDENT conversed with peers in English/Spanish”.
STUDENT was cooperative and compliant during testing. He/She conversed
comfortably with the examiner and rapport was easily established. He/She put forth a
good effort and remained attentive throughout the testing sessions. He/She appeared to
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enjoy the one to one nature of the assessment. His/her motivation during testing
appeared to be consistent/inconsistent. STUDENT’S response time to verbal tasks was
X. STUDENT’S language consisted of single words, phrases and complete sentences.
He/she exhibited good attending skills and contributed good effort toward testing. For
example STUDENT X. Other behaviors noted during testing include X.
VALIDITY OF ASSESSMENTS:
Your report must include a statement about the validity of the assessments conducted. If the
results are not a valid estimate of student’s ability, indicate so here.
Example
“A credentialed speech language pathologist administered all speech and language testing.
Test and assessment materials and procedures used for the purposes of assessment and
placement of individuals with exceptional needs were selected and administered so as not
to be racially, culturally, linguistically, or sexually discriminatory. Child’s dominant
language was considered in selecting assessment instruments. Tests have been validated
for the specific areas of educational need. The results that have been provided accurately
reflect the child’s current abilities as measured by the assessment procedures.
CURRENT ASSESSMENTS:
Include a brief description of the tests used and a brief description of scores. Save your analysis
for the eligibility section of the report.
Clinical Evaluation of Language Fundamentals – Fourth Edition
The Clinical Evaluation of Language Fundamentals-4th Edition, is an individually
administered clinical for the identification, diagnosis, and follow-up evaluation of language and
communication disorders for people for 5-21 years old.
Subtest Scaled Score
Core
Language
(13-21)
Receptive
Language
(13-21)
Recalling Sentences
Formulated Sentences
Word Classes – Receptive
Word Classes –
Expressive
Word Classes – Total
Word Definitions
Understanding Spoken
Paragraphs
Sentence Assembly
Semantic Relationships
Sum of Subtest Scaled
Scores
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Expressive
Language
(9-21)
Language
Content
(13-21)
Language
Memory
(13-21)
Name
Date
Standard Score
Confidence Interval (90%
Level)
Percentile Rank
Percentile Rank
Confidence Interval
Descriptive Classification
The Receptive One Word Picture Vocabulary Test - Fourth Edition (ROWPVT-4)
The Receptive One Word Picture Vocabulary Test – Fourth Edition (ROWPVT-4) is an
individually administered, norm-referenced assessment of an individual’s ability to match a
spoken word with an image of an object, action, or concept. Appropriate for English – speaking
individuals ages 2 through 80+ years. A word is spoken by the examiner and the examinee
indicates (by pointing or verbal response) which of the four illustrations on a page matches the
word.
Standard Score
Percentile Rank
You may choose to summarize your assessment data after each assessment but leave your
eligibility analysis for the Summary and Eligibility section.
SUMMARY AND ELIGIBILITY:
This is the section of your report where you interpret all the assessment data as it relates to
eligibility criteria.
ELIGIBLITY STATEMENT
In order to qualify for special education services under the eligibility category of speech and
language , the student must: 1) demonstrate difficulty understanding or using spoken language;
2) to such an extent that it adversely affects his or her educational performance; and 3) it cannot
be corrected without special education and related services.
In addition, the student must meet the definition of having at least one of five possible disorders
in any of the following areas: 1) articulation; 2) abnormal voice; 3) fluency; 4) language
disorder; or 5) hearing loss which results in a language or speech disorder.
Student has a suspected speech and language disorder in (insert all areas tested) of spoken
language. Each of these areas will be addressed in turn.
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Date
Articulation
Pursuant to 5 CCR section 3030(c)(1)(A) a student qualifies as having an articulation disorder if:
1) the pupil displays reduced intelligibility or an inability to use the speech mechanism; 2) which
significantly interferes with communication; and 3) it attracts adverse attention.
Significant interference in communication occurs when the pupil's production of single or
multiple speech sounds on a developmental scale of articulation competency is below that
expected for his or her chronological age or developmental level, and which adversely affects
educational performance.
Reduced intelligibility or an inability to us the speech mechanism
Should address both and state whether either one is met.
Significantly interferes with communication
Remember the definition above.
Attracts adverse attention
Courts view this exactly as it sounds…are student’s peers looking at the student
differently due to student’s speech.
Adversely affects academic performance
Grades, performance on benchmarks, state testing, classroom participation, teacher
interview. Also consider behavior.
PRESCHOOL: Look at the preschool learning foundations for expected age appropriate
skills.
Requires special education and related services
Are there less restrictive interventions? The law prefers general education
accommodations to special education services.
Based on the foregoing, Student does/does not meet the eligibility requirements for an
articulation disorder.
Language Disorder
Pursuant to 5 CCR section 3030(c)(1)(4) a student “has an expressive or receptive language
disorder when he or she meets one of the following criteria:
(A) The pupil scores at least 1.5 standard deviations below the mean, or below the 7th percentile,
for his or her chronological age or developmental level on two or more standardized tests in one
or more of the following areas of language development: morphology, syntax, semantics, or
pragmatics. When standardized tests are considered to be invalid for the specific pupil, the
expected language performance level shall be determined by alternative means as specified on
the assessment plan, or
(B) The pupil scores at least 1.5 standard deviations below the mean or the score is below the 7th
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Date
percentile for his or her chronological age or developmental level on one or more standardized
tests in one of the areas listed in subsection (A) and displays inappropriate or inadequate usage of
expressive or receptive language as measured by a representative spontaneous or elicited
language sample of a minimum of fifty utterances. The language sample must be recorded or
transcribed and analyzed, and the results included in the assessment report. If the pupil is unable
to produce this sample, the language, speech, and hearing specialist shall document why a fifty
utterance sample was not obtainable and the contexts in which attempts were made to elicit the
sample. When standardized tests are considered to be invalid for the specific pupil, the expected
language performance level shall be determined by alternative means as specified in the
assessment plan.”
At Least Two Standardized Tests – Subsection A
Expressive or receptive language deficits in morphology, syntax, semantics, or pragmatics on
two standardized tests
Must be 1.5 standard deviation below mean or below 7th percentile for age or
developmental level.
Adversely affects academic performance
Grades, performance on benchmarks, state testing, classroom participation, teacher
interview. Also consider behavior.
PRESCHOOL: Look at the preschool learning foundations for expected age appropriate
skills.
Requires special education and related services
Are there less restrictive interventions? The law prefers general education
accommodations to special education services.
Based on the foregoing, student does/does not meet the eligibility requirements for a
language disorder due to expressive/receptive deficits in _____________________ areas.
One Standardized Test and a Language Sample – Subsection B
Expressive or receptive language deficits in morphology, syntax, semantics, or pragmatics on
one standardized test
Language sample
Minimum is 50 utterances. Recorded or transcribed and analyzed. If not obtainable,
state why including context.
Adversely affects academic performance
Grades, performance on benchmarks, state testing, classroom participation, teacher
interview. Also consider behavior.
PRESCHOOL: Look at the preschool learning foundations for expected age appropriate
skills.
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Date
Requires special education and related services
Are there less restrictive interventions? The law prefers general education
accommodations to special education services.
Based on the foregoing, student does/does not meet the eligibility requirements for a
language disorder due to expressive/receptive deficits in _____________________ areas.
Abnormal Voice
A pupil has an abnormal voice which is characterized by persistent, defective voice quality,
pitch, or loudness.
Persistent and defective voice quality, pitch or loudness
Must be persistent, i.e., constant!
Adversely affects academic performance
Grades, performance on benchmarks, state testing, classroom participation, teacher
interview. Also consider behavior.
PRESCHOOL: Look at the preschool learning foundations for expected age appropriate
skills.
Requires special education and related services
Are there less restrictive interventions? The law prefers general education
accommodations to special education services.
Based on the foregoing, student does/does not meet the eligibility requirements for abnormal
voice.
Fluency Disorder
A pupil has a fluency disorder when the flow of verbal expression including rate and rhythm
adversely affects communication between the pupil and listener.
Deficit in the flow of verbal expression, including rate and rhythm
That adversely affects communication between the pupil and listener
Interviews with the teacher is key here.
Adversely affects academic performance
Grades, performance on benchmarks, state testing, classroom participation, teacher
interview. Also consider behavior.
PRESCHOOL: Look at the preschool learning foundations for expected age appropriate
skills.
Requires special education and related services
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Name
Date
Are there less restrictive interventions? The law prefers general education
accommodations to special education services.
Based on the foregoing, student does/does not meet the requirements for a fluency disorder.
Hearing Loss
A student qualifies for speech and language with a hearing loss which results in a language or
speech disorder and significantly affects educational performance.
Hearing loss
Speech and language disorder
Student must also meet the eligibility of one of the other speech and language
eligibilities.
Adversely affects academic performance
Grades, performance on benchmarks, state testing, classroom participation, teacher
interview. Also consider behavior.
PRESCHOOL: Look at the preschool learning foundations for expected age appropriate
skills.
Requires special education and related services
Are there less restrictive interventions? The law prefers general education
accommodations to special education services.
Based on the foregoing, student does/does not meet the requirements of a speech and language
impairment due to hearing loss.
Example:
“STUDENT meets eligibility as a student with ________ disability. Final determination
will be made by the IEP team.”
Recommendations:
 If the student is eligible for services, provide a recommendation for services (including
frequency and duration)

Accommodations and modifications to support language and communication in the
classroom.
_______________________________________
Signature
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