Eastern Upper Peninsula
Intermediate School District
315 Armory Place, P.O. Box 883
Sault Ste. Marie, MI 49783
906 632-3373
SLI
SPEECH and LANGUAGE REPORT
Student’s Name:
Referral Date:
DOB:
CA:
Referred by:
Report Date:
Grade:
District: Please Choose District
Reason for Referral:
School:
SUMMARY OF EVALUATION DATA:
List of Evaluations:
Assessment Name:
Date
Cognitive:
Applicable Health History:
Evaluation Date:
Hearing
Medical
Physical:
Developmental
Problems
Source:
Educational Implications:
Adverse effect on educational performance
Yes
No Attach classroom teacher’s report
Eligibility recommended:
Articulation
Language
Fluency
Voice
LD Expressive Language
Language
Not eligible for services
Observation of Communication Impairment in LRE (Optional) Date:
Specific problem(s) observed:
Specific problem(s) to be addressed by TSLI if eligible:
Amount & type of service to be recommended:
Direct:
Indirect:
Amount of time: Minutes:
Hours:
Frequency:
Weekly
Monthly
Parent Input:
Behavioral description of child in testing situation:
LD Written
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Student’s Name:
SPEECH:
Articulation/Phonology:
Informal test of articulation:
Formal test of articulation:
Defective Phonemes: indicate as follows: ---=Omit
D=Distortion Enter substitution
Consonants – Approximate development age cited (Iowa:Smit 1986)
3.0
3.5
4.0
4.5
5.0
5.5
7.0
8.0
9.0
m
n
G
m
V
F
Sh
R
m
p
b
h
d
w
k
Vowels
Vowels
Vowels
as in
as in
as in
v
l
l
z
ch
zh
th
ng
th(v)
Errors are:
Consistent
Inconsistent
Phoneme errors persisting beyond age in which maturation alone might be expected to correct deviation:
Processing errors, if any have persisted:
STIMULABILITY
Intelligibility
Easily stimulated:
Close approximation:
Not stimulated:
Estimated:
Actual:
Oral Motor Functioning:
%
%
Within expectations
Problems noted
Voice Quality:
Within normal limits
Strident/harsh/hoarse/breathy/aphonic/hypernasal/hyponasal
Low/high in pitch
Habitual pitch too low
Pitch break
Intensity:
Inappropriate vocal intensity Please specify:
Resonance:
Hypernasality (Vowels)
Hyponasality
Nasal emission (Consonants)
Mixed
Assimilated nasality – nasality on vowels adjacent to /m, /n/, /ng/:
Contributing Factors:
Hearing
Surgery
Medication
Vocal abuse
Allergies
Temporary health problems
Duration:
Medical Information:
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Student’s Name:
Further Observations:
Cough/throat clearing
Marked neck muscle activity during phonation
Marked upward or downward excursion of the larynx during phonation
Fluency:
Fluency evaluation: Rhythm of speech interrupted by:
prolongations of sounds
syllables
words
blocking
interjections
repetitions
Background Information: Age of onset:
Provided by:
Parental expectations/concerns:
Student’s expectations/concerns:
Situations that provoke/increase stuttering:
Fluency: - A minimum taped language sample of 5-10 minutes is recommended
Stuttering Behavior:
Method A
Frequency of blocks:
less than 3%
Duration:
less than .6 sec
.6 to 4
3-10%
5-15
Method B:
Stuttered words per minute:
0-3
4-5
Total words spoken per minute:
111-150
Secondary Characteristics:
Verbal Behavior
Prolongations
Repetitions
Whole word
Syllable
Single phoneme
Abnormal rate
11-24%
25% or more
16 sec. or more
6-10
90-109
11+
70-89
69 or less
Non-verbal Behavior
Lack of eye contact
Tremors
Facial grimaces
Extraneous body movement
Evidence of frustration
Change in pitch
Glottal fry
Revisions
Interjections
Starters
Language – Is there a basic or associated language problem?
Yes
No If “Yes,” indicated by
Oral Motor Functioning:
Rate of Speech:
Adequate
Slow
Fast
Oral Peripheral Examination – Speech mechanism was:
Within normal limits
Atypical and adequate/inadequate for speech production
Language: Please list tests used for evaluation
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Student Name:
Expressive Language:
Within normal limits
tense formations;
subject-verb agreement;
omission of articles;
question formations;
Below expectancy. Deviations were noted in:
sentence length;
verb
pronoun usage, prepositions;
singular-plural;
negation, possessives;
semantic complexity;
syntactic complexity;
sequencing
description.
Use of Oral Language:
Within normal limits
Below expectancy. Deviations were noted in:
Rate of formulating responses;
circumlocutions;
verbal perseveration;
tangentiality;
answering questions appropriately;
appropriateness of
utterances in relation to context;
eye contact, ritualistic greeting and closings;
topic initiation;
topic maintenance;
topic closure.
Language Sample Analysis:
Spontaneous Sample:
MLU:
Predominant sentence type:
Simple
Complex
Number of utterances:
Interrogatory
Syntax/Morphology (Structure): Rate by using: X=Problem; 0=Not observed; W=Within normal limits
Word order:
Pronouns:
Prepositions:
Demonstrative:
Articles:
Plurals:
Locative:
Conjunctions:
Possessives:
Contractions:
Verb tense:
Negation:
Questions:
Adverbs:
Comparatives:
Errors are:
Consistent
inconsistent
Semantics (Content)
1. Describe vocabulary used:
2.
Problems noted:
Dysnomia
Space
Circumlocutions
Time
Quantity
Non-specific words (i.e., frequent use of it)
Echolalia
Other (Please describe:
Fillers/stallers (i.e., un, a-a-a, m-m)
Pragmatics (Use): Rate by using: X=Problem; 0=Not observed; W=Within normal limits
1. Situational Use:
a.
Greetings
b.
Eye contact
c.
Requests:
Objects
Actions
Information
d.
Denials
e.
Stating information
2.
Initiates topic
3.
Maintains topic
4.
Turn talking
5.
Organizing and sequencing ideas
6.
Elaboration of ideas
7.
Variety of vocabulary
8.
Verbal perseveration
9.
Appropriateness of utterances to topics/situation
Paralinguistic Aspects: Rate by using: : X=Problem; 0=Not observed; W=Within normal limits
Prosody:
Intelligibility:
Fluency:
Vocal intensity:
Vocal quality:
Inflection:
Juncture:
Summary of Language Sample Analysis:
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Student’s Name:
DIAGNOSTIC IMPRESSIONS AND CONCLUSIONS:
SUMMARY AND RECOMMENDATIONS:
_________________________________________
Speech/Language Pathologist
____________
Date
5/12
SAVED: WORD/LUCY/WEBSITE DOCS/SPEECH-LANGUAGE IMPAIRMENT/SPEECH-LANGUAGE DOC.
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