Speech-Language Evaluation/Screening Checklist

Child’s Initials _______ Case Mgr _________ Teacher(s) _______________Grade ______ Eval Due
_________
● Permission to Evaluate
○ signed & dated by parent _____
● Screening
○ Hearing ( __pass __fail) date ____/____/____ Health/Hearing Notes ___________________
○ Articulation Screen: No errors _____ Errors noted ______
○ Language Screen: At/above Criterion _____ Below Criterion _____
○ Voice WNL _____ Voice concerns _____
○ Fluency WNL _____ Fluency concerns _____
○ Other:
● Evaluation
○ Articulation: No errors _____ Errors noted ______ (continue below)
■ Formal Test ________________________
■ Teacher Checklist _____ Oral Periph Exam _____ Observation _____
○ Language: At/above Criterion _____ Below Criterion _____ (continue below)
■ Comprehensive Test: __________ Additional Test/Subtest __________
■ Teacher Checklist _____ Language sample _____ Observation _____
○ Other:

● Paperwork/drafts for proposals-

○ Invitation to conference signed ____ 2nd notice ______
○ Official eligibility paperwork (draft): _______
○ Paperwork for file (as applicable):
■ Evaluation report ________ (2 copies- parent and file copy)
■ Teacher reports ________
■ Social Appraisal/Case History_______
■ Results for hearing _____
■ Observation form _____
○ IEP (draft) ________ (if initial or continuing, N/A if exiting or not eligible)
○ Prior Written Notice (draft) _____
○ Parent Handbook ______
○ Permission to Place ________ (if initial placement)
○ Teacher notified of accommodations: _____
○ Other:

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