Multidisciplinary Team Evaluation Report Template - Speech Impaired - Voice - South Bend Community School Corporation

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South Bend Community School Corporation
Special Education Services
Multidisciplinary Team Evaluation Report
Speech Impaired – Voice
Date of the Evaluation: _________________________________ Purpose:
£
Initial Eligibility
£
Re-evaluation
Student____________________________________ ID#: __________________ STN#: _____________________
School___________________________ Referred by:
£
Parent
£
Teacher ___ Other (Specify_______________)
Student has:
£
Normal hearing
£
Hearing loss
£
Referred for audiological follow up
£
£
Student uses assistive or augmentative technology for communication? Yes
No
If yes, what type?
___________________________________________________________________________________________
Members of the Multidisciplinary Team:
Speech-language Pathologist (SLP):_______________________Classroom Teacher:_______________________
Other:_______________________________ Parent/Guardian:_________________________________________
VOICE ASSESSMENT ADMINISTERED:__________________________________________________________
£
Pitch:
£
normal
£
too low
£
too high
£
pitch breaks
£
limited variability
£
Loudness:
£
normal
£
too loud
£
limited variability
£
Quality:
£
normal
£
hoarse
£
breathy
£
harsh
£
shrill
£
strident
£
variable
£
£
£
£
Nasal Resonance:
normal
denasal
hypernasal
£
Oral Resonance:
£
normal
£
lack of
£
excessive
Other characteristics: __________________________________________________________________________
Parent’s observations/comments summary (attach social and developmental history):________________________
___________________________________________________________________________________________
Teacher’s observations/comments summary (attach classroom teacher’s report):___________________________
___________________________________________________________________________________________
SLP’s observations/comments:___________________________________________________________________
___________________________________________________________________________________________
Oral examination results:________________________________________________________________________
Achievement test results (see classroom teacher’s report). ISTEP, NWEA, Brigance, curriculum-based
assessment, etc. Date(s) administered and results:___________________________________________________
___________________________________________________________________________________________
Comments on any effect the speech impairment may have had on this student’s achievement test results and/or
academic and/or functional performance:___________________________________________________________
___________________________________________________________________________________________
Medical information educationally relevant to speech impairment:________________________________________
___________________________________________________________________________________________
£
(√ if applicable)
Organic basis suspected for speech impairment; physician’s report attached.
Exclusionary factors: (√ if applicable or N/A if not applicable:
£
Speech impairment appears to be maturational in nature
£
Sole reason for referral is student’s native language is not English.
Based on the results of this
£
evaluation
£
re-evaluation, this student to appears to be
£
eligible
£
not eligible
for special education and related services. However eligibility is determined by the case conference committee.
_______________________________________
Speech-language Pathologist
8/18/12
South Bend Community School Corporation
Special Education Services
Multidisciplinary Team Evaluation Report
Speech Impaired – Voice
Date of the Evaluation: _________________________________ Purpose:
£
Initial Eligibility
£
Re-evaluation
Student____________________________________ ID#: __________________ STN#: _____________________
School___________________________ Referred by:
£
Parent
£
Teacher ___ Other (Specify_______________)
Student has:
£
Normal hearing
£
Hearing loss
£
Referred for audiological follow up
£
£
Student uses assistive or augmentative technology for communication? Yes
No
If yes, what type?
___________________________________________________________________________________________
Members of the Multidisciplinary Team:
Speech-language Pathologist (SLP):_______________________Classroom Teacher:_______________________
Other:_______________________________ Parent/Guardian:_________________________________________
VOICE ASSESSMENT ADMINISTERED:__________________________________________________________
£
Pitch:
£
normal
£
too low
£
too high
£
pitch breaks
£
limited variability
£
Loudness:
£
normal
£
too loud
£
limited variability
£
Quality:
£
normal
£
hoarse
£
breathy
£
harsh
£
shrill
£
strident
£
variable
£
£
£
£
Nasal Resonance:
normal
denasal
hypernasal
£
Oral Resonance:
£
normal
£
lack of
£
excessive
Other characteristics: __________________________________________________________________________
Parent’s observations/comments summary (attach social and developmental history):________________________
___________________________________________________________________________________________
Teacher’s observations/comments summary (attach classroom teacher’s report):___________________________
___________________________________________________________________________________________
SLP’s observations/comments:___________________________________________________________________
___________________________________________________________________________________________
Oral examination results:________________________________________________________________________
Achievement test results (see classroom teacher’s report). ISTEP, NWEA, Brigance, curriculum-based
assessment, etc. Date(s) administered and results:___________________________________________________
___________________________________________________________________________________________
Comments on any effect the speech impairment may have had on this student’s achievement test results and/or
academic and/or functional performance:___________________________________________________________
___________________________________________________________________________________________
Medical information educationally relevant to speech impairment:________________________________________
___________________________________________________________________________________________
£
(√ if applicable)
Organic basis suspected for speech impairment; physician’s report attached.
Exclusionary factors: (√ if applicable or N/A if not applicable:
£
Speech impairment appears to be maturational in nature
£
Sole reason for referral is student’s native language is not English.
Based on the results of this
£
evaluation
£
re-evaluation, this student to appears to be
£
eligible
£
not eligible
for special education and related services. However eligibility is determined by the case conference committee.
_______________________________________
Speech-language Pathologist
8/18/12

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