Lafayette Parish School System



Lafayette Parish School System DATE_________________

STUDENT__________________________________

ELEMENTARY-LEVEL SPEECH-LANGUAGE SCREENING FORM

SCREENING RESULTS: _____Passed _____Failed

_____Rescreen (area): _____Language _____Articulation _____Voice _____Fluency

IDENTIFICATION INFORMATION:

DOB___________________ AGE ___________ SEX ____________ RACE________ GRADE__________

SCHOOL____________________________________ TEACHER__________________________________

PARENT’S NAME____________________________________ PHONE_______________________________

The teacher reported the following speech-language behaviors in the classroom:

____________________________________________________________________________________________

____________________________________________________________________________________________

Date parent contacted_____________________ Parent comment/reaction____________________________

____________________________________________________________________________________________

Medical History______________________________________________________________________________

____________________________________________________________________________________________

ARTICULATION

_____Adequate _____ Inadequate Norms:___________________________

_____1. Sounds in words: Repeat underlined words. Errors noted:__________________________________

_____2. Sounds in sentences. Circle errors in the following sentences:

Sound Sentences

r 1. The Rabbit ran over the farm.

l 2. Later we will listen.

v 3. Five boys gave me valentines.

pl 4. The purple plate was plastic.

ch 5. Charlie ate a batch of chocolate chip cookies.

sh 6. Sherry is washing her dish.

s 7. Jason sent it to the office.

j 8. Jerry and Jeff enjoyed the fudge.

Th (voiceless). 9. Martha thanked Kathy for the tablecloth.

vcalic r 10. Turn over the circles.

th (voiced) 11. Feathers are smooth.

z 12. Zip your gloves.

The following phonemes were stimulable: _______________________________________________________

Inconsistent _________________________________________________________

3. Connected Speech

______readily intelligible ____unintelligible

______intelligible with noticeable errors ______Other errors noted in conversation

______________________________________

LANGUAGE

______Adequate _______Inadequate

A. Receptive

_____1. Memory for Sentences – Use Articulation section sentences 1-4.

Criteria: Grades 1-2 (3/4) Grades 3-4 (4/4)

Sentence: 1.______ 2.______ 3.______ 4.___________2.

_____2. Memory for Paragraphs (Read paragraph to student and ask questions.)

Criteria: Grades 1-2 (5/9) Grades 3-5 (6/9)

a. Mary went to the store Monday. She only had ten cents so she bought two pieces of bubble gum.

Who went to the store? ___________________ How much money did she have? ___________

When did she go? ________________________ What did she buy/_______________________

b. Jenny was having a birthday party. She was going to be five years old. Her mother baked a chocolate cake and bought her some strawberry ice cream.

Why was Jenny having a party? ___________________________How old is Jenny?_________

Who baked Jenny a cake? ____________________ What flavor was the ice cream?__________

Was the cake chocolate?__________________

B. Expressive

_____1. Oral Vocabulary (must contain 2 statements regarding function or description per item)

a. Grade 1 Grade 2

What is (a) ______________? What is a (a) ________________________?

1. nurse____________________________ 1. rocket______________________________

2. umbrella_________________________ 2. party_______________________________

3. desk_____________________________ 3. turtle_______________________________

b. Grade 3 Grades 4 & 5

1. circus____________________________ 1. destroy_____________________________

2. library___________________________ 2. human_____________________________

3. parade___________________________ 3. hero________________________________

4. ill__________________________________

5. passenger___________________________

_____2. Similarities/Differences

**omit for Grades 1 & 2 Same Different

a. dog/cat _____________________________ ________________________________

b. circle/watch _____________________________ ________________________________

c. clock/watch _____________________________ ________________________________

d. penny/nickel _____________________________ ________________________________

e. ball/orange _____________________________ ________________________________

_____3. Antonyms: Discontinue after two consecutive errors. Directions:

Say the words listed below, one at a time. Pause after each for the student to respond. The statement, “Tell me the opposite of” may be used before each word.

Tell me the opposite of: Acceptable Responses # of Correct Responses Approx. Grade Level

1. long short

2. bottom top

3. front back

4. mother father 1-4 1

5. start stop, finish 5-8 2

6. him her, she 9-12 3

7. white black 13-16 4

8. asleep awake 17-20 5

9. sweet sour

10. early late, tardy

11. subtract add

12. heavy light

13. increase decrease, loss

14. multiply divide

15. empty full

16. north south

17. narrow wide

18. argue agree

19. enemy friend, ally

20. public private

_____4. Analogies – Read the incomplete sentences, one at a time. Say “I’m going to read some sentences. I want you to complete each one. Reread the incomplete sentence if needed.

No. of Correct Responses 1-3 4-6 7-9 10-12 13-16

Approx. Grade Level Kdg. 1 2 3 4 & 5

1. An apple is to red as grass is to ______.(green)

2. Mark is a boy. Amy is a ________. (girl)

3. Mother is a woman. Father is a ________. (man)

4. You hit a ball with a bat and a nail with a __________. (hammer)

5. You wear socks on your feet and gloves on your _________. (hands)

6. A boy runs. A fish ____________. (swims)

7. Red is to STOP as green is to __________. (go)

8. Eyes are to seeing as ears are to __________. (hearing)

9. Carrots are to vegetables as apples are to __________. (fruit)

10. Dog is to puppy as cat is to ______________. (kitten)

11. Plus is to add as minus is to ____________. (subtract, take away)

12. Tuesday is to day as December is to _______. (month)

13. Add is to subtract as multiplication is to __________. (division)

14. January is to month as spring is to __________. (season)

15. Mayor is to city as governor is to __________. (state)

16. Foot is to length as pound is to ___________. (weight)

_____5. Classification – Read the incomplete sentences, one at a time. Pause after each for the student’s response. Say “I’m going to read some sentences to you. I want you to complete each one. Reread the incomplete sentence if needed.

No. of Correct Responses: 1-3 4-6 7-9 10-12 13-15 16-18

Approx. Grade Level Kdg. 1 2 3 4 5

1. Blue, red and green are all __________. (colors, kinds of crayons or paint)

2. A ball, a circle and a wheel are ________. (round, circles)

3. A cat, a dog and a rabbit are all _________. (pets, animals, mammals)

4. Apples, peaches and oranges are all ________. (fruit, round, to eat, grow on trees)

5. A coat, a shirt and a hat are all_________. (clothing, to wear, to keep you warm)

6. Mother, brother, and father are all _________. (people, persons, part of the family)

7. Monday, Thursday, and Saturday are all ____________. (days of the week, part of the week)

8. Arm, leg, and head are all __________. (Parts of the body, part of us)

9. Pencil, pen and chalk are all for ___________. (writing, marking, making your name)

10. January, May and December are all ___________. (months, months of the year)

11. Christmas, Easter, and Thanksgiving are ___________. (holidays, days we celebrate, special days)

12. A pond, a lake, and a sea all __________. (have water in them, have fish in them)

13. Spring, winter, and summer are all _________. (seasons of the year, seasons)

14. A fly, a beetle and a mosquito are all ___________. (insects, things that fly)

15. Baseball, golf, and skating are all ____________. (sports, athletics)

16. California, Texas and Florida are all __________. (states)

17. North, east and west are all __________. (directions, on a compass)

18. Poodle, cocker spaniel and German shepherd are all ________. (dogs, kinds of dogs)

_____6. Conversational Speech – Activities that may stimulate verbal expression include the following: Exploring an interesting object or toy; Playing with puppets; Explaining a familiar game; Telling how to wrap a present, or get dressed; Telling “What’s Wrong” in a silly picture; Describing scenes from a View Master; Playing with race cars; Describing a picture/object that is “hidden” from the examiner; Telling about family/favorite activities.

1. _________________________________________________________________________________________

2. _________________________________________________________________________________________

3. _________________________________________________________________________________________

4. _________________________________________________________________________________________

5. _________________________________________________________________________________________

6. _________________________________________________________________________________________

7. _________________________________________________________________________________________

8. _________________________________________________________________________________________

9. _________________________________________________________________________________________

10. _________________________________________________________________________________________

11. _________________________________________________________________________________________

12. _________________________________________________________________________________________

Results: _____Appropriate skills developmentally. MLU:________________________

_____Language is considered appropriate for regional differences and dialect.

_____Inappropriate skills which were characterized by inappropriate usage or omissions of the following structures: (CHECK ERRORS NOTED)

_____prepositions _____verb tenses

_____pronouns _____possessives

_____copulas _____sentence formation (syntax)

_____articles _____subject-verb agreement

Other errors noted:_______________________________________________________________

VOICE

_____Within normal limits _____At Risk

_____Atypical nasal resonance and/or nasal emission _____Chronic hoarseness

_____Possible structural abnormalities of hard or soft palate _____Inappropriately low pitched

Comments:__________________________________________________________________________________

____________________________________________________________________________________________

FLUENCY

_____Within normal limits _____At Risk

Excessive repetitions: _____Sounds _____Syllables _____Words _____Phrases

Excessive hesitations: _____Prolongations _____Blocks _____ Circumlocutions______

Secondary Characteristics (list):________________________________________________________________

ORAL-PERIPHERAL EXAMINATION

1. Teeth Comments:

A. General Condition: _____Adequate _____Inadequate ________________________________

B. Occlusion: _____Adequate _____Inadequate ________________________________

2. Palate

A. Intactness of Hard Palate: _____Normal _____Abnormal ________________________________

B. Intactness of Soft Palate: _____Normal _____Abnormal ________________________________

C. Condition of Uvula: _____Normal _____Abnormal ________________________________

3. Tonsils: _____Present _____Absent

4. Tongue

A. Appearance: _____Normal _____Abnormal

B. Carriage _____Normal _____Abnormal

C. Movement: _____Normal _____Abnormal

HEARING SCREENING

250 500 1K 2K 4K 8K

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