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

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South Bend Community School Corporation
Special Education Services
Multidisciplinary Team Evaluation Report
Speech impaired – Articulation
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:________________________________________
Test(s) administered:_________________________________________________________________________
Results:_____________________________________________________________________________________
___________________________________________________________________________________________
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, DIBELS, 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)
____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 – Articulation
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:________________________________________
Test(s) administered:_________________________________________________________________________
Results:_____________________________________________________________________________________
___________________________________________________________________________________________
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, DIBELS, 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)
____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