1234 School Address

Pretty City, CA 12345

Ph. 555-444-4444
Fax. 555-555-5555
School Website

CONFIDENTIAL REPORT OF SPEECH AND LANGUAGE EVALUATION

Name: Grade:
Birth Date: School:
Chronological Ethnicity:
Age:
Report Date: Testing Date(s):
Name of Type of Initial X Trienni
Assessor: Assessment: al
Other:

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 Institution Code.

A Note on the Use of the Template:

This template is not intended to be utilized as a sample report. It is recommended that all items in RED be
REMOVED as these items have only been included to provide suggestions of information you may wish to
incorporate, and not intended to remain in the report. All information presented within the headings in this
template should be written for the ease of understanding for all IEP participants and be written in paragraph
format instead of using bullet points. Not all sections of the report are required, therefore removal of sections is
recommended depending on the assessment that was completed and the student for whom it was completed.

Reason for Referral

The purpose of this assessment is to assist the IEP team in determining eligibility for special education services as well as
to inform educational planning based on the students identified strengths and needs.

 Source of referral (teacher, parent, Student Success Team, Intervention Team, DIS provider, etc.)
 Primary reason why student was referred

Background Information Relevant to This Report

 History of the service. Eligibility under SLI?

 Statement of current eligibility for Speech and Language and level of service (if not initial assessment)
 Type of service offered
 Type of assessment
 Other identified concerns
 Access to interventions and response
 Previous Assessment(s): (remove if initial)
Date Type Assessor Summary of Data
8/13/12 Test of Auditory Mrs. SLP
Processing
7/22/12 Goldman Fristoe Mr. Language
Test of
Articulation 2

Hearing Screening Completed by Mrs. Nurse Amazing on (date)

Hearing
Within normal limits
Wears Hearing Aids
Date Tested:
Comments:

English Language Learner Information

This is an assessment of an English language learner (ELL). The normal processes of second language acquisition, as well
as manifestations of dialect and social linguistic variance, were not diagnosed as a disabling condition. Materials and
procedures were provided in the student’s native language/mode of communication in a form most likely to yield
accurate information regarding the student’s current levels of functioning. Any exceptions to the above will be addressed
in the following report.

Primary Language: Dominant Language:

Language in which English Proficiency Level Include reading, writing,

Assessments were (CELDT scores): speaking, listening and
Administered: overall score
Instructional program: Examples Additional Information:  Interpreter used?
 Structured English  Bilingual SLP?
Immersion  Conducted under
 Dual Language standard
 Bilingual Waiver conditions?

Current Evaluation

The following procedures were components of this evaluation:

Parent Input:
 Rating Scales and Questionnaires
 Interview

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 Student Input:
 Interview
 Rating Scales and Questionnaires

Educational Team Input:

 Cumulative Records Review
 Observation of the Student
 List complete name of assessment: list assessor if not the individual writing the report
 Rating Scales and Questionnaires: completed by Ms. Teacher Extraordinaire
 Speech and Assessment Name: conducted by Mr. SL Personality
 Vision and Hearing Screening: conducted by Mrs. Nurse Amazing

Observations and Interviews

Teacher Observation and/or Interview:

Parent Observation and/or Interview:

Student Interview:

Speech and Language Therapist Observations:

 Observations in classroom and other appropriate settings in areas of both strength and
weakness, including relationship of skills observed to academic functioning if applicable (i.e.
expressive and receptive language).
 EXAMPLE: Testing was completed over several sessions. Student presented as a well-mannered,
reserved youngster who readily engaged with the examiner and demonstrated good attention
and effort in completing all assessment tasks. Student viewed all pictures before making his/her
choice. Student was observed asking questions and self-correcting when appropriate. Test
results were considered a valid reflection of current functioning levels in the areas assessed.

Assessment Results

Scope of the Evaluation:

Based on review of existing evaluation data, a formal assessment was conducted in the following areas:
Language
Social Communication and/or Functional Language (Pragmatics)
X Voice
Phonological Processes
Fluency
X Articulation
Augmentative or Alternative Communication

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Articulation:
 Name and description of tests administered
 Test Results
 Summary
 Sound production
 Stimulability
 Intelligibility
 Oral motor exam
 Effect on communication
 Developmental in nature?

Voice:
 Name and description of tests administered
 Test Results
 Summary
 Characteristics
 Etiology- any current physical conditions
 Effect on communication
 Pitch, Quality, loudness

Fluency:
 Name and description of tests administered
 Test Results
 Summary
 Rate of Speech
 Rhythm of speech
 Effect on communication

Language:
 Name and description of tests administered
 Test Results
 Summary
 Effect on communication
 Informal language sample description/ transcription/ analyzation
 Vocabulary skills
 Sentence length and complexity
 Wants/ needs/ ideas
 Ability to relate stories with proper sequence
 morphology, syntax, semantics

Social Communication and/or Functional Language (Pragmatics):

 Name and description of tests administered
 Test Results
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  Summary
 Effect on communication
 Effect on social interaction with peers/ adults

Phonological Processes:
 Name and description of tests administered
 Test Results
 Summary
 Effect on communication
 Effect on ability to follow directions within the classroom setting

Augmentative or Alternative Communication:

 Current device used and effectiveness
 Name and description of tests administered
 Test Results
 Summary

Summary and Conclusions

Evaluation Procedures:
In accordance with State and Federal guidelines, no single test or score will determine a student's eligibility. Test results
are examined in conjunction with all available sources of information by the IEP team, including teachers, parents,
specialists and others. Assessments utilize formal and informal tools, observation, interviews, and file reviews.

As a part of this evaluation, a qualified related services assessor carefully considered existing evaluation data,
information and evaluations provided by the parent, current classroom based assessments and observations by teachers
to determine the presence or absence of a speech and/or language deficit, which may be contributing to his/her
educational need.

Assessment procedures are selected so as not to discriminate on the basis of gender, culture, language, ethnicity or
disability. Test results accurately reflect student's skills and abilities unless otherwise specified in the body of the report.
Administered tests have demonstrated validity for the purposes in which they were utilized unless otherwise described in
the body of the report.

This report was developed to assist the IEP Team in determining eligibility and need for special education and related
services according to the code of Federal Regulations, Sections 300.304 to 300.306. The IEP team shall take into account
all relevant information regarding the student prior to making recommendations regarding eligibility. No single score or
product of scores shall be used as the sole criterion for the decision of the IEP team as to the student’s eligibility for
special education. (From CCR 5 Sec. 3030)

Assessment Summary:
 The summary should consist of one or two paragraphs that provides a brief description of
relevant background information and the assessment findings.
 Name, referral question, age, grade, ethnic background, EL status, instructional
program
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  Brief review of relevant background information (attendance, educational history,
etc.)
 Impact of skills on functioning in the general education classroom

Assessment Conclusions:
Based on the results of this report, the student appears to/ does not appear to meet eligibility criteria in
the area of Speech and Language Impairment.

Rationale:

Speech or Language Impairment (SLI): A student has a language or speech disorder once it is
determined that the student's disorder meets one or more of the following criteria:

Articulation disorder: The student displays reduced intelligibility or an inability to use the
speech mechanism which significantly interferes with communication and attracts adverse
attention.

Significant interference in communication occurs when the student'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. A student does not meet the criteria for an articulation disorder if the
sole assessed disability is an abnormal swallowing pattern.
X Abnormal voice: A student has an abnormal voice which is characterized by persistent, defective
voice quality, pitch, or loudness
X Fluency disorders: A student has a fluency disorder when the flow of verbal expression
including rate and rhythm adversely affects communication between the student and listener.
Language disorder: The student has an expressive or receptive language disorder when he
or she meets one of the following criteria:
 The student 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 student, the expected language performance level shall be
determined by alternative means as specified on the assessment plan, or
 The student scores at least 1.5 standard deviations below the mean or the score is below
the 7th percentile for his or her chronological age or developmental level on one or more
standardized tests in one of the areas listed in section 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 50 utterances. The language
sample must be recorded or transcribed and analyzed, and the results included in the
assessment report. If the student is unable to produce this sample, the language, speech,
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 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 student, the expected language
performance level shall be determined by alternative means as specified in the
assessment plan.

Speech or language performance is not due to cultural, environmental, or economic disadvantages,

limited school attendance, or second language acquisition. The disability may not be corrected solely
through modification of regular education.

The IEP team will meet to discuss assessment results and will make final determinations regarding
special education eligibility and services at that time.

Recommendations

The following interventions are intended as suggested strategies to facilitate learning and not to be interpreted
as accommodations mandated in an IEP.

 Each student will have a different set of needs due to their unique profile. Thus, the
recommendations should be individualized.
 Recommendations should not include 1:1 aide, discussion of placement, service minutes, etc.
These are all decisions of the IEP team.

______________________________________ ________________________________
Mr./Ms./Mrs. SLP Date
Speech and Language Pathologist

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