aac evaluation tools - the georgia speech-language hearing ...€¦ · 2. speech and language...

AAC Evaluation

Tools

Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology

3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144

Ph: 770-974-2424 Fax: 1-866-384-6451

[email protected] www.mydynamictherapy.com

Dynamic AAC Evaluation Protocol | V. Clarke 2011

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Dynamic AAC Evaluation Protocol

Step I: Initial Client Information Form

Client Info: Personal

Client Name: DOB:

Social Security Number: Gender:

Date of Onset: Date of Current Plan of Treatment:

Student: yes no

Name of School:

Grade:

Employed: yes no Name of Employer:

Medicare # Medicaid #

Managed Care Medicaid yes no Managed Care Medicaid ID#

Does client currently own a communication device:

yes no

Make and Model:

Date of Purchase:

Client Info: Residence

Place of Residence:

Home Facility

If Facility, Name:

Facility Main Phone:

Address:

Home Phone: County:

Alternate Phone:

Email:



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Client Info: Medical Diagnosis

Medical Diagnosis:

ICD-9 Code:

Speech Diagnosis:

ICD-9 Code:

Date of Onset, Accident, or Diagnosis:

Type of Accident:

Employment Auto Other

Date of Evaluation:

Client Info: Family Contact/Legal Guardian Use Client Address Info

Contact Name: Relationship to Client:

Contact Home Phone: Address:

Contact Alternate Phone:

Contact Email:

Contact Fax:

Client Info: Treating Physician

Physician Name: Physician Address:

Physician Phone:

Physician Fax:

Physician Email:

Medicaid Provider # Physician UPIN

Physician NPI # Physician License #

Medicaid Primary Care Physician Name

Medicaid Primary Care Physician Phone

Client Info: Private Insurance Use Client Address Info

Name of Insurance Company:

Address:

Employer Name:

Policy # Group #



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Policy Holder Name: Case Manager:

Policy Holder SS# Policy Holder Relationship to Client

self spouse parent legal guardian Policy Holder Date of Birth:

Client Info: Other Insurance

Use Client Address Info

Name of Insurance Company:

Address:

Employer Name:

Policy # Group #

Policy Holder Name: Case Manager:

Policy Holder SS# Policy Holder Relationship to Client

self spouse parent legal guardian Policy Holder Date of Birth:

Client Info: Alternate Funding-

Please list and describe in detail any alternate funding sources

Prescription from Primary Physician

Copies of ALL insurance and Medicaid/Medicare cards, front/back



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Statement of Problem: Please explain the concerns which brought you to this office

Desired Outcome of Treatment: What would you like to happen as a result of today’s visit and our subsequent involvement with your family?



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Step II: Augmentative Communication/Speech Generating Device Evaluation

1. Background Information

Team Members Planning to Attend Evaluation Present at Evaluation?

Educational History In Grade Level:

Early Childhood/Preschool

Elementary- Grade: ___________

College

Other

Completed Grade:

Elementary School High School College Post-Graduate Other

Type of Program:

Special Education General Education Combination of Special and General Education Other:

No School

Current Therapy Services: Therapy Frequency Site Therapist/Phone #

Speech Therapy

Occupational Therapy

Physical Therapy



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Other:

Medical History (add pertinent medical procedures, history, medications, if any)

Vocational History:

Unemployed

Attends workshop/day program: __________________________________

Employed at _________________________________________________

Additional Comments (vocation)

Additional Comments (Background Information):



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2. Speech and Language Status

Speech and Language Status Determined by:

report (e.g. client, family, other therapists, teachers)

informal assessment

formal testing

Formal Tests Administered and Results:

Receptive Language: No deficits in Comprehension

Comprehends:

single words

phrases

sentences

conversation

one-step directions

two-step directions

multiple-step directions

yes/no questions

choice questions

wh-questions

Additional information:



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Expressive Language Communicates Using:

facial expression

pointing

gestures

eye gaze

formal signs

vocalizations

speech at the word level sentence level

objects/pictures/symbols/printed words

voice output communication device

Speech Intelligibility:

____% intelligible with familiar listeners

____% intelligible with unfamiliar listeners

Additional Information:

Written Language

Produces by handwriting: Produces by typing:

Given single words (with or

without symbols), produces:

Nothing Nothing Nothing

Letter Letter 2-3 word phrases

Words (copying) Words (copying) Simple sentences

Words (independently) Words (independently) Complex sentences

Sentences Sentences

Paragraphs Paragraphs

Adaptations For Typing

Standard keyboard ABC keyboard

Writing tool adapted Spelling on device

QWERTY keyboard Word prediction support



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Reading

Functional Reading Comprehension Reading Comprehension Level

Nothing Age-appropriate (at grade level)

Sight words only Below age-level (grade level)

Sentences Approximate Grade Level:

Paragraphs


Cognition

Memory for tasks presented:

within functional limits

partially limited

severely limited

Attention to tasks presented:

within functional limits

partially limited

severely limited

Learning:

demonstrated new learning during this evaluation (e.g., new techniques, devices).

Summary:

possesses the cognitive abilities to effectively use an augmentative communication device to achieve

functional communication goals.

Additional Information (Cognition):



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Summary of Speech and Language Status o Emergent/Functional

o Difficult to fully assess receptive language o Beginning to communicate using a variety of methods (gestures, body language, facial

expressions, simple symbols) o Requires assistance from the communication partner o Communicates a limited number of messages in a small set of specific contexts or routines

o Context Dependent/Situational

o Understands simple and clear symbols; beginning to understand more abstract symbols. o Understands most communication about things that are preent. May misunderstand references to

people, situations and items that are not present o Communicates effectively in a limited nmber of situations OR communicates in a limited way

across a variety of situations o Overall ability to communicate effectively depends on the environment, topic or communication

partner o Has very limited ability to creatively combine symbols to create new messages o Limited literacy skills

o Independent/Creative

o Age appropriate receptive language o Follows the linguistic rules appropriate for his/her age o Writes and spells at or near age level o Able to combine single words, spelling, and phrases together to create novel and flexible

messages about variety of subjects.



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3. Current Communication Needs

Environments: please check all environments the client participates in

Home/Residence

School

Work

Medical Facility

Face-to-Face

Telephone

Community

Support Group

Other:

______________________

Partners: please check all partners with whom the client interacts

Immediate Family

Extended Family

Friends

Peers

Co-Workers

Medical professionals

Home health assistants/caregivers

Individuals in the community

Other___________________

Teachers

Residential staff

Topics: please check all topics about which the client needs to communicate

Activities of Daily Living (ADLs)

Medical needs

Medical/Personal/Legal decision-making

Emergency needs/information

Personal needs

Personal information

Other: _________________________

Functions:

Ask questions

Respond to questions

Social interaction (family and community)

Social etiquette

Resolve/prevent communication breakdowns

Other: _________________________



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Summary and Prognosis:

Choose one of the following:

Daily functional communication needs cannot be met using natural speech or low-tech/no-tech augmentative

communication techniques.

OR

Improvements in the quantity and intelligibility of clietn’s speech are unlikely, possible, expected

at this time. At this time, verbal skills do not allow him/her to meet all of his/her daily communication needs

nor do they allow him/her to continue to develop/ regain age-appropriate language skills.

OR

Client has a degenerative condition for which traditional speech/language therapy is not effective. His/her

natural speech does not allow him/her to meet the majority of his/her daily communication needs.


Prognosis for functional use of an augmentative communication system:

excellent good fair poor



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4. Sensory and Motor

The focus of this section is to provide information regarding vision, hearing and motor skills as they relate to

the use of an augmentative communication device. Information for parts of this section may be provided by an

occupational therapist, if one is involved in the evaluation process.

Vision unaided and functional for AAC use

corrected (glasses/contacts) and functional for

AAC use

functional use of AAC system required vision

accommodations (check necessary

accommodations)

Concerns regarding functional visual processing

(cortical visual skills) in absence of acuity difficulty

Vision Accommodations: increased font size

increased symbol size color contrast

auditory feedback other:

Hearing unaided and functional for AAC use

Hearing Aids L R bilateral and

functional for AAC use

Modifications needed (with/without hearing

aids)

Hearing Accommodations: increased volume

visual cues (display of message, highlight on activation)

headphones dual display for communication

other:

Additional information related to visual and hearing abilities of client or family members/caregivers:



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Motor: Mobility:

no assistive devices

a cane

a quad cane

a walker

a manual wheelchair ( self-propelled or partner-dependent)

a power wheelchair ( joystick, head array, or sip and puff switch)

a scooter

Head:

Control: complete partial, no

Functional Movement: complete partial, no

Hand Use:

Control: complete partial, no

Functional Movement: complete partial, no

Accuracy for Touching Targets: phone keyboard computer keyboard

alternate keyboards: button size ______




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Step III: Hands-On Trials and Results 4. Required Features

Use this section to identify features of a communication device that must be present for your client to be the

most functional communicator possible. Some features may be needed immediately and others may be needed

for language growth and development. You may include a large number of features here. You will use this list to

justify your equipment recommendation in a later section.

Required Features

Language

Message generation via spelling (language structure)

Message generation via combinations of single words (language structure)

Message generation via pre-stored messages (language use)

Combination of message generation modes for quick communication and creation of novel messages

(language use and language structure)

Variety of symbols to represent words or concepts

Ability to use digital photos to represent words or concepts

Ability to use scenes to set the context for communication

Word, character, and phrase prediction to speed rate of communication or decrease effort

when spelling

Other: ______________________________________________________________________

______________________________________________________________________

Access

Carrying case for protection while device is being transported and used

Wheelchair mounting system for easy and safe access in all environments

Desk mount for access at various tabletops

Standard size keyboard for touch typing to optimize communication speed

Keyboard to allow for exploration and literacy learning

Keyboard to allow for spelling of novel messages

Multiple keyboard layouts

Adjustment of access settings (e.g., hold time, scanning speed) to best meet patient’s needs

Accessible via direct selection

Accessible via eye gaze

Accessible via keyguard

Accessible via mouse or mouse alternative (e.g., trackball, Head Mouse, Tracker)

Accessible via joystick

Accessible via one- or two- switch scanning

Accessible via Morse code

Accessible via multiple modes to accommodate for changes in condition over time

Other: ______________________________________________________________________



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______________________________________________________________________

Device Characteristics Portability for use in multiple environments

Durability to withstand daily use

Battery power to allow for use throughout the day

Voice output for communication in all environments

Synthesized speech for production of novel messages

Feedback (e.g., button click, message window highlight) to assist in message preparation/selection

Dual display for interactions with hearing impaired individuals or in noisy environments

Flexible font size and color for clearest visual presentation

Flexible number and size of messages per page for optimal ease of use and comprehension

Ability to save, retrieve, and edit longer files for use during story telling, speeches, and

caregiver direction

Other: ______________________________________________________________________

______________________________________________________________________

Connections to the World

Telephone access to allow for communication of emergency information

Control of electronic appliances (e.g., lights, fan) for increased independence

Email/texting capability for interaction with community (medical appointments, information, vocational

interactions etc)

Internet accessibility for interaction with community (medical appointments, information, vocational

interactions etc)

Other: ______________________________________________________________________

______________________________________________________________________



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5. ASSESSMENT OF SPECIFIC EQUIPMENT AND TECHNIQUES- Use one form per device trialed.

Fill in details, check items patient can accomplish, mark N/A for features not available on this device

Trial One: DEVICE/SOFTWARE/MATERIALS: ___________________

TRIAL SPECIFICS

Length of Trial:

Considered but rejected without trial due to:

inability to meet required features lack of symbols to represent language

lack of voice output limited ability to meet communication needs in the near future

weight or size limiting portability small size not meeting physical or visual needs

other:

Describe concerns: _______________________________________________________________

Trial during evaluation session Longer trial (> 1 week) for ________________________

On-Going Trials with loaned equipment

daily

weekly

monthly

On-Going Access to Equipment (evaluation for purpose of assessing effectiveness of current equipment)


Techniques To Elicit Communication:

discussion response to questions role play functional activity (play, look at magazine)

other: (describe) ________________________________________________________________

Describe Evaluation Stimulus Activities:

Care for Device: independent transport of device partner transport of device

independent battery/charger maintenance partner assisted battery maintenance

turn on/off independent on/off with partner assistance

volume control independently partner assisted volume control

independent programming capability partner assisted programming

programming will be accomplished by partners

Size of Display/Screen: 6” screen 7” screen 10” screen 12” screen 15” screen

Size of Symbols: Keyboard 1” 2” >3”



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ACCESS METHODS: (consider physical, sensory, behavioral and attention skills and needs)

Direct Selection with Touch, with touch enter delay, with touch exit delay (to decrease accidental

activation or repetitive tapping)

Keyguard: number of locations= 6 8 12 15 20 30 40 60 100 150

Range of Motion: Sufficient on Left Right Both

_______________________________________________________________________________________

Scanning:

Scan Type: Automatic Scanning with Single Switch

Single Switch with Dwell Select with ______ second hold to select

2-Switch (switch to move scan target + switch to select)

Scan Cues: Zoom Highlight Border Highlight Inversion Highlight

Auditory Scan Cue: voice selection ___________________

Private Speaker Output

Device Speaker Output at _____ volume

Scan Pattern: Row/Column

Column/Row

Left/Right

Left/Center/Right

Six Zones

Linear

Top/Bottom

_______________________________________________________________________________________

Joystick/Mouse: Selection Via: Pause External Switch Fire (joystick only)

Zoom Highlight Border Highlight Inversion Highlight

Audio Feedback: voice selection ________________________________



Speed: ____________________



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_______________________________________________________________________________________

Eye Tracking/Eye Gaze:

Selection Via: Blink Dwell

Hold Time: ________________seconds


Fill Type: Bottom Up Contract Drain (color to no color)

Audio Feedback Click yes no

Calibration: both eyes left eye right eye

_______________________________________________________________________________________

Other:_____________________________________



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COGNITIVE ACCESS TRIAL #1:___________________________________________

Size of Symbols Necessary for Attention/Focus:

Keyboard 1” 2” >3”

Number of Symbols on Page: 2-4 8 12 20

40 60 >100

Navigation: single page, no navigation can navigate pages – list pages:_____________________

Navigation Support: independent verbal prompts taught in context repetition hand over hand

visual cue-button shape, highlight taught in context partner assisted navigation

Type of Symbol: Object Photograph Symbol Word Spelling

Page Format: Grid Free Form Scene

Vocabulary Organization: (check all that apply)

Generative/Creative Word Based (ex: Gateway)

Context Based (scenes or grids related to particular settings

Activity Based (scenes/grids related to specific activities

Pragmatically Organized (function- ex: want something, greetings, something’s

wrong…)

Quick Messages (yes/no, hi/bye, let me/you do it, more/all done, good/bad)

Message Unit: Sentence Phrase Word Letter

Mean Length of

Utterance/Word

Based:

1 word 2 words 3-5 words using carrier

phrases only

Ex: I want…I see…I go…I

like…

on single page

with navigation to other

pages to complete sentence

>3 words independently

combined

on single page

with navigation to

other pages to

complete sentence

Functions: exploration/learning request respond comment share information reject

social exchange escape

Vocabulary Expansion: Multiple levels Dynamic Display Encoding

Editing Functions: close popup delete clear message

Rate: Word prediction Abbreviation expansion Pre-stored messages



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Trial #2: DEVICE/SOFTWARE/MATERIALS: ___________________

TRIAL SPECIFICS

Length of Trial:





other:




daily

weekly

monthly





other: (describe) ________________________________________________________________












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_______________________________________________________________________________________

Scanning:









Column/Row

Left/Right

Left/Center/Right

Six Zones

Linear

Top/Bottom

_______________________________________________________________________________________






Speed: ____________________



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_______________________________________________________________________________________








_______________________________________________________________________________________

Other:_____________________________________



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COGNITIVE ACCESS: TRIAL #2: ___________________________________________




40 60 >100











wrong…)



Mean Length of

Utterance/Word

Based:


phrases only


like…

on single page




combined

on single page

with navigation to

other pages to

complete sentence








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Trial #3: DEVICE/SOFTWARE/MATERIALS: ___________________

TRIAL SPECIFICS

Length of Trial:





other:




daily

weekly

monthly





other: (describe) ________________________________________________________________












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_______________________________________________________________________________________

Scanning:









Column/Row

Left/Right

Left/Center/Right

Six Zones

Linear

Top/Bottom

_______________________________________________________________________________________






Speed: ____________________



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_______________________________________________________________________________________








_______________________________________________________________________________________

Other:_____________________________________



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COGNITIVE ACCESS TRIAL #3:________________________________________________




40 60 >100











wrong…)



Mean Length of

Utterance/Word

Based:


phrases only


like…

on single page




combined

on single page

with navigation to

other pages to

complete sentence








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Trial 1: _________________________________

Conclusion:

Most appropriate device at this time

Meets some needs, but will continue looking with the following concerns:

Trial 2: _________________________________

Conclusion:



Trial 3: _________________________________

Conclusion:





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Step IV: Post-Evaluation Recommendations and Follow-Up Planning 6. Summary and Recommendations

SGD AND ACCESSORIES RECOMMENDED

Check recommended device and accessories:

DEVICE

Dynavox Maestro

Dynavox Tango

Dynavox V

Dynavox Vmax

Dynawrite

Dynavox Xpress

PRC Springboard

PRC Vantage Lite

PRC Echo

Saltillo Alt-Chat

Saltillo Silk

Saltillo NovaChat 7

Saltillo NovaChat 10

Tobii C8

Tobii C12

iTouch

iPad

Other:

SWITCH

Buddy Button

Big Buddy Button

Microlight

Plate Switch

Cap Switch

Cup Switch

Mini Cup

Square Pad

Soft

Trigger Switch

Switch Joystick with Push

Mini Joystick

SCATIR

Other:

ACCESSORY

Extra Charger

Headmouse

Tracker

Headpointer

Switch Mount

Eye Gaze Camera: __________________

Carrying Case

Accessible Carrying Case

Extra Battery

Other:

SOFTWARE/APPs

Series 5 Speaking Software

Speaking Dynamically Pro

Boardmaker Studio

The Grid



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iOS App



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7. Treatment Plan and Follow-Up

INTERVENTION SCHEDULE

Recommended Follow-Up:

No follow-up treatment

Limited number of follow-up treatment sessions after receipt of device: _______ (#)

On-going therapy with _________minutes per session; __________number of sessions per week

Individual therapy recommended

Group treatment recommended

Treatment is available at: _________________________________________________

INITIAL TREATMENT GOALS FOR DATES: _______________________________________

Example Goals: Select from example goals below that are most appropriate for patient or use Goals Grid

examples

Operational:

Using written instructions will program at least 10 messages on existing pages with ____ % accuracy

(within ______week/months).

Patient will demonstrate the ability to program messages with ______ % accuracy


Patient will demonstrate comprehension of basic maintenance and operations

(on-off, adjusting volume) of the device with _____ % accuracy (within ______week/months).

Other:__________________________________________________________________________

Basic Communication:

Patient will call for help from a spouse/caregiver in another room in emergency situations with ____%

accuracy (within ______week/months).

Given a specific message to find, patient will navigate to the correct page

independently

with minimal cues

with moderate cues with ____ % accuracy (within ______week/months).

During conversation, patient will navigate to the correct page

independently

with minimal cues


Patient will communicate basic/medical needs and feelings to family/caregivers with _____% accuracy


Patient will greet and initiate conversation



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independently

with minimal cues

with moderate cues with _____% accuracy (within ______week/months).

Patient will ask questions, respond to questions, and express opinions

independently

with minimal cues

with moderate cues with ____% accuracy (within ______week/months).

Patient will communicate basic personal information

independently

with minimal cues

with moderate cues with _____ % accuracy (within ______week/months).

When asked, patient will select desired activities

independently

with minimal cues


Other: ____________________________________________________________________________

Language Learning:

Patient will use the (recommended device) to make simple sentences (e.g.., subject + verb + object)

appropriate to the current activity page

independently

with minimal cues


Using: core words keyboard combination of core words and spelling,

Patient will formulate _________word sentences appropriate to the current activity

independently

with minimal cues


Patient will use word prediction to spell a core set of 3-5 letter words

independently

with minimal cues


Other:______________________________________________________________________________

Communication in the Community:

Patient will participate in a phone conversation

independently

with minimal cues




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Patient will describe physical symptoms and ask questions while interacting with a physician or other

healthcare provider

independently

with minimal cues

with moderate cues with _____ % accuracy (within ______week/months).

Patient will engage in social interactions with friends in a variety of community settings

independently

with minimal cues


Patient will ask questions and respond in community-based interactions

(e.g., at the bank, ordering in a restaurant)

independently

with minimal cues


Patient will participate in support groups

independently

with minimal cues

with moderate cues with ____ % accuracy(within ______week/months).

Other:______________________________________________________________________________

Self-Advocacy:

Patient will instruct caregivers about care requirements and preferences

independently

with minimal cues


Patient will participate in family and medical planning decisions

independently

with minimal cues


Other:____________________________________________________________________________



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PATIENT/FAMILY SUPPORT OF SGD

Responsible Parties

Patient Family Caregiver

(name)

__________

Manufacturer

Representative

(name)

______________

Therapist

(name) ______________

______________

Other

(name)

______

Therapy to address

above goals

Continued trials

with SGD

N/A- not

recommended

Group tx:

Individual tx:

Group/Individual

therapy:

Initial Training

Initial Customization

(programming,

vocabulary selection,

intervention planning)

On-Going Training

and Modification

Maintenance of

Device

Warranty

Maintenance

Management

NECESSARY FUNDING PAPERWORK

Check when obtained Date

Medicaid/Insurance Cards Copied

Benefits Assignment Signed by Parent/Consumer

Doctor’s Prescription

AAC/SGD Evaluation Written

Quote from Manufacturer



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Long Term Goal and Expected Outcomes: Patient will communicate functionally in his/her home, school

and community to meet medical, social and life needs using a combination of speech, written and voice output

device communication.

Clinical Provider: _________________________ __________________________________

Vicki K. Clarke, MS CCC-SLP date

Physician Involvement Statement: It is in my opinion that patient requires the therapeutic services as described in the above Evaluation and Plan

of Treatment in order to meet a medically necessary level of functioning.

Physician Signature:________________________________ Date: _________________________________

cc: parent, physician, clinic file, Medicaid records

*Content adapted from The Funding Manager software, copyright 2008, Dynavox Technologies, Pittsburgh,

PA

Georgia Project for Assistive Technology www.gpat.org Permission to photocopy is granted for non-commercial purposes if this credit is retained.

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Augmentative Communication Evaluation Summary

Student: Date of Birth: Age: Date(s) of Evaluation: System:

Access Evaluation Informal measures were utilized to evaluate the student’s access skills. The following is a summary of his/her performance: Direct Selection:

Student could utilize direct selection to access targets (i.e., toys, familiar objects, manipulatives, etc.) placed within easy reach using

Hand left right both Finger - Specify: _____ left right both Other – Specify: Eyegaze response - Describe eyegaze response including optimal symbol size,

placement, etc. When using direct selection, the student: Consistently accessed targets No Yes Crossed midline to access targets No Yes Required significant response time No Yes - Specify: Required a large target area No Yes - Specify: Accessed symbols in all locations No Yes - If No, explain:

(If student is able to utilize direct selection, skip remainder of access section and move to Symbol Evaluation) Adapted Direct Selection:

Student could utilize adapted equipment to access targets using Splint Head pointer Keyguard/grid Mouthstick Adapted pointer – Describe

Student could utilize computer based adapted direct selection using:

Mouse Trackpad Trackball Joystick keyguard/grid Keyboard Head pointing system Mouse Mover

(Complete Computer Access Evaluation for more information, if needed)

Using the devices listed above, the student:

Required use of Accessibility Features in Windows operating system – Specify: Moved the mouse in designated direction: right left up down diagonally Visually tracked mouse arrow or highlight Navigated to desired locations on communication device Executed a single click to activate location Executed a double click to open an application Maintained a steady position long enough to execute a dwell function activation Consistently accessed targets Crossed midline to access targets Required significant response time If Yes - Specify: Required a large target area If Yes - Specify: Accessed symbols in all locations Other – Specify

Comments:


2

Switch Access: Student could not use direct or adapted direct selection to access symbols. The following alternative input method was assessed during this evaluation: (use a variety of tools, such as toys, computer software, power control units, etc.) The following switches were used during this evaluation:

Switch Activation Site Location/ Mount

Activate Hold/ Maintain

Release Reactivate

ex: Big Red right hand laptray/right side

yes maintain for 2/3 seconds

unable to release without cues

needs verbal cues

Switch responses were: Spontaneous Verbally cued Visually cued Partial Physical Assistance Full Physical Assistance

Switch access used by the student:

Remote switch access # of switches # of switches Switch type Switch type

Scanning switch access Scan Mode Scan Method Visual scanning Automatic scanning Auditory scanning Directed (step) scanning Inverse scanning Scan Pattern Other – Specify: Linear Row/Column Block/Row/Column Customized – Specify:

Morse Code access # of switches Switch type

Symbol Evaluation Informal measures were utilized to evaluate the student’s symbolic skills. The following is a summary of his/her performance: Symbol Identification:

Student was unable to participate in a formal symbol evaluation due to Symbol usage was assessed during device evaluation.


3

Student was able to complete a formal symbol evaluation. The following symbols were used:

Referent Object

Specify Type

Photograph Realistic Picture Line Drawing

Size:

Printed Text

Size:

Using the symbols evaluated above, the student: Could not use symbolic representation due to Identified object/tactile/tangible representation system – Specify Identified photographic representation system Identified realistic picture representation system Identified line drawing representation system (PCS, DynaSyms, etc.) Identified text based symbols – Specify: letter word

Using the representation system listed above, the student:

Could identify symbols by (check all that apply): label/name function action size color category association

Student was able to view and utilize up to ______ symbols in a: linear row/column

arrangement Symbol Accommodations for Vision Needs: (Consult with Vision Specialist if student diagnosed with vision impairment)

Student required symbol adaptations to accommodate visual needs: large symbol size – Specify: high contrast spacing between symbols grid separating symbols textured symbol system tangible symbol system Symbol/Vocabulary Usage: Using the symbols introduced in the Symbol Identification Evaluation, the student’s ability to use symbols as a means of communication and expressive language was assessed through informal measures.

Student used symbols with communicative intent for the following purposes: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject

Student did so with the following level of support: spontaneous model verbal prompt visual prompt gesture hand/hand facilitation (student directed) partial physical assistance full physical assistance (adult directed)

Student sequenced vocabulary to generate phrases/sentences – Specify number of symbols ___ Student required prompts to sequence vocabulary

Level of prompting required: model visual verbal physical


4

Augmentative Devices Evaluated

Based on information obtained in the accessing and symbol evaluation areas, communication systems with the following features were presented:

Non-voice output systems:

System(s) utilized: Object board/box Describe:

Eyegaze board Describe:

Picture exchange system Describe:

Picture book/board Describe:

Picture wallet Describe:

Word board Describe:

Letter board Describe:

Visual schedule Describe:

Activity Utilized classroom activity game toys social routine other – specify:

Access: Direct selection hand left right finger left right

Adapted direct selection adapted pointer head pointer

Scanning access: Live voice/Partner assisted

scanning Partnered visual scanning

Symbol System: Symbol type: object/tangible/tactile photograph realistic picture line drawing text based spoken prompt/cue

Symbol arrangement: linear row/column

Number of symbols utilized: Initial Final

Symbol recognized by: label/name function action size color category association

Vocabulary Usage: Communicative intent: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject

Vocabulary sequencing: Number of symbols sequenced: independently with prompts

Level of prompting: model visual verbal physical

Vocabulary Organization:

single message phrase based single word combination – Specify:

Comments:


5

Single level static display systems:

Device(s) utilized: Activity Utilized classroom activity

game toys social routine other – specify:



Switch access: remote switch

# of switches switch type



Symbol System: Symbol type: object/tangible/tactile photograph realistic picture line drawing text based




Vocabulary Usage: Communicative intent: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject




single message phrase based single word combination – specify: Fitzgerald Key Arrangement

Activity Based Minspeak

Comments:


6

Multiple level static display systems:

Device(s) utilized:



Adapted direct selection

adapted pointer head pointer joystick

Switch Access Scanning access

Scan mode: Visual scanning Auditory scanning

Scan method: Automatic scanning Directed (step) scanning Inverse scanning

Other – Specify Scanning pattern:

Linear Row/Column Block/Row/Column

Custom – Specify: Morse Code


Symbol System: Symbol type: object/tangible/tactile photograph realistic picture line drawing text based




Vocabulary Usage: Communicative Intent: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject






Related Skills: Student could independently/physically change overlays Student could utilize multiple levels Student could change levels on the device Student could match appropriate overlay to level Student could select appropriate overlay for activity Student could utilize volume control on device

Comments:


7

Dynamic display systems: dedicated integrated

Device(s)/software utilized: Type of Speech Output: Digitized Synthesized


Access: Direct Selection hand left right finger left right

Adapted direct selection adapted pointer head stick

Computer based adapted direct selection mouse trackpad trackball joystick keyboard head pointing system mouse mover








Symbol System: Symbol type: photograph realistic picture line drawing text based




Vocabulary Usage Communicative Intent: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject






Related Skills:: Student could demonstrate categorization skills in number of topic areas Student could use recall memory to locate vocabulary not displayed on current screen Student could remember navigational pathways Student could correct errors in navigation Student could generate a single message utilizing multiple pages Student could see communication device display with ease

Advanced Features Student could utilize text to speech function to generate novel messages Student could utilize word prediction to assist with spelling/rate enhancement Student could utilize large vocabulary pool to generate novel messages

Student could use preprogrammed vocabulary software - Specify:

Comments:


8

Minspeak based systems:

Device(s) utilized: Type of Speech Output: Digitized Synthesized




Computer based adapted direct selection mouse trackpad trackball joystick keyboard head pointing system








Symbol System: Symbol type: photograph realistic picture line drawing text based




Vocabulary Usage: Communicative Intent: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject




single message phrase based single word combination – specify:


Related Skills:: Student could demonstrate categorization skills in number of topic areas Student could use recall memory to locate vocabulary not displayed on current screen Student could sequence symbols to retrieve vocabulary – specify: Student could remember navigational pathways Student could correct errors in navigation Student could generate a single message utilizing multiple pages Student could see communication device display with ease

Advanced Features Student could utilize text to speech function to generate novel messages Student could utilize large vocabulary pool to generate novel messages

Student could use preprogrammed vocabulary software Specify:

Comments:


9

Dedicated Letter based systems:

Device(s) utilized: Activity Utilized classroom activity

game toys social routine other – specify:



Computer based adapted direct selection joystick keyboard








Spelling Accuracy: Spelling sufficient to be recognized by text to speech engine: Word prediction is utilized to assist spelling/rate enhancement

Vocabulary Usage: Student could generate sufficient words through spelling to convey thoughts Student could formulate a complete thought or sentence Student could use appropriate grammar when formulating sentences

Related Skills Student could remember navigational pathways Student could correct errors in navigation Student could see communication device display with ease

Advanced Features Student could utilize text to speech function to generate novel messages Student could utilize large vocabulary pool to generate novel messages Student could use word prediction feature to enhance rate

Comments:


10

Recommendations

Based on the results of this evaluation, the following recommendations are made for this student:

System Recommendations:

At this time, student does not require an augmentative/alternative communication system.

If checked, specify why:

The student would benefit from a non-voice output communication system to supplement device

use or to serve as a beginning means of communication. The following device(s) are suggested:

Object board/box Eyegaze board Picture exchange system Picture book/board Picture wallet Word board Letter board Live voice/Partner assisted scanning Partnered visual scanning Visual Schedule box - Describe: Other

The student would benefit from a voice output augmentative communication device to supplement

his/her existing communication skills. The following device features are recommended at this time:

Voice Output:

Digitized voice output Synthesized voice output Access:

Direct selection access Adapted direct selection Computer based access Remote switch access Single switch access Dual switch access Visual scanning access Auditory scanning access

Physical Features: Large target area Accommodates object symbol Single level Multiple levels Static display Dynamic display Printed output Text to speech capability (spelling) Keyguard/grid Portable Lightweight Wheelchair mount* Shoulder Straps/Carry Case Button Covers (Tech Caps, Snap Switch Caps, etc.)

Vocabulary Features: Activity based Minspeak based Letter/word/text based Large vocabulary capacity Commercially Available Vocabulary Software Packages Other-Specify:


11

The following system(s) contain(s) the above suggested features and is/are felt to be appropriate for the student’s use at this time. Trial periods should be conducted with each system listed prior to a final determination.

Name of Device: _______________________________ Vendor: *Consultation with Physical Therapist, device manufacturer and wheelchair vendor is suggested for mounting of communication system utilized by non-ambulatory student



Access Method The student should access symbols on the communication device/display through:

Direct selection: Hand left right both Finger-Specify: _____ left right both

Eyegaze response - Describe eyegaze response including optimal symbol size, placement, etc.

Adapted direct selection: Splint Head pointer keyguard/grid Optical Head pointer Mouthstick Adapted pointer – Describe

Computer based adapted direct selection: Mouse Trackpad Trackball Joystick Keyboard Head pointing system Mouse Mover

The following adaptations are required to enhance student access when using the above access methods:

large symbol size – Specify: high contrast grid separating symbols textured symbol system tangible symbol system Spaces between symbols - Specify: Other adaptations - Specify:

Switch access used by the student:

Remote switch access # of switches # of switches Switch type Switch type

Scanning switch access Scan Mode Scan Method Visual scanning Automatic scanning Auditory scanning Directed (step) scanning Inverse scanning Scan Pattern Other – Specify: Linear Row/Column Block/Row/Column Customized – Specify:


12

Morse Code access # of switches Switch type

Symbol System The following symbols are recommended to represent selected vocabulary:

Tangible/Tactile symbols Whole/Real objects (the actual object) Miniature objects (doll-sized representations or magnets) Parts of objects (wheel from a car, button from shirt) Associated Objects (clock for time, straw for drink) Textures or shapes (triangle for eat, circle for drink, sandpaper for places, etc.)

Photographs Realistic picture representation system – Specify: Line drawing representation system – Specify: Text /Printed words – Specify: letter word

In order to enhance access, the most appropriate symbol size is The initial symbol set should not exceed _____ symbols per display. As the student becomes more proficient in identifying and accessing symbols, additional symbols may be added to the display. Additional Comments/Recommendations:

Vocabulary/Symbol Use Vocabulary should be selected to promote participation across communication environments. The following selection method(s) are suggested to assist in selecting appropriate vocabulary for the student:

Ecological/environmental inventory Activity based inventory Social inventory (i.e., social language) Peer observation Student observation Teacher/family/student interview

Vocabulary should also be selected to permit expression of a range of language functions including the following:

gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject

Student should sequence symbols to generate phrases/sentences Yes No

If yes, the student should begin sequencing ______ symbols

Student requires prompts to sequence symbols Yes No If yes, level of prompting required: model visual verbal physical

Vocabulary Organization Selected vocabulary should be programmed using the following language organization method:

Single message Activity Based (single level) Activity based (static multiple levels) Activity Based (dynamic display) Minspeak based (single level with activity row) Minspeak based (dynamic display)


13

Using the language organization method designated above, vocabulary should be organized utilizing the following language level(s):

Complete messages (i.e., 1 message/1 hit) Combine short phrases (i.e., carrier phrases, noun phrases, verb phrase filler items, etc.) Single Words (i.e., 1 word/1 hit) organized by: activities

categories grammar Fitzgerald Key Arrangement (syntactical format) Color coding to assist word group recognition

Additional Comments/Recommendations:

Strategies to Enhance Device Use When integrating the student’s communication system into the classroom environment, the following strategies should be considered:

Visual Strategies and Cueing The classroom environment should be engineered for successful communication. Use visual supports to enhance communication, behavior, and learning. Use picture-based task analysis to promote independence in task completion. Use a classroom/individual daily picture-based schedule to support transition. Use Super Symbols (behavior cue symbols) to address inappropriate behavior.

Integration The selected communication system should be available to the student throughout the

school day. The communication system should be used in a variety of settings and activities with

appropriate vocabulary. Integrate student’s communication system into behavior modification plan to address

behavioral concerns.

Teaching Strategies Customize AAC displays to include personal vocabulary. Interact with students using AAC in natural situations using natural cues and consequences. Develop a consistent method of cueing/prompting. Model the use of the AAC system by pointing to the appropriate symbol as you speak.

The student’s system should be used as a method to develop receptive language as well as expressive language.

Provide immediate and consistent feedback to a student’s communication attempts. Create communication opportunities throughout the school day. Provide access to a continuum of AAC supports (communication device, communication

boards, communication rings, etc.) Provide multiple modality immersion (signs, pictures, spoken language, gestures, etc.) Develop a method for backing up student’s vocabulary system/device. Consider the use of a flashlight for a supplement or an alternative or to finger pointing. Utilize a preferred/less preferred or nothing/preferred strategy when teaching choice-making.

Staff Supports

All school staff working with the student should receive training in the programming and use of the selected communication device.

Consult with a physical therapist, occupational therapist and/or wheelchair vendor regarding mounting issues.


14

Student Progress Data should be collected to verify student’s use of his/her system. The student’s use of the device should be carefully monitored and changes in programming

should be made as needed. Trial use of communication system should be implemented to determine appropriateness.

Additional Comments/Recommendations:

Augmentative Communication Evaluation Conducted by: Name Position Date Name Position Date

AAC Funding

Tools

SPEECH-LANGUAGE PATHOLOGY EVALUATION FOR SPEECH GENERATING DEVICE (SGD)

II. CURRENT COMMUNICATION IMPAIRMENT Impairment Type, Severity The patient presents with __________ due to .

Given the severity of the communication impairment as described above the patient is functionally nonspeaking.

As indicated above, the patient’s speaking rate was words per

minute (WPM). Research on speaking rate and intelligibility in degenerative diseases has found speaking rates less than or equal to 50% of normal (range 190 – 220 WPM) are predictive of imminent precipitous decline (e.g., to the point of no usable speech in less than 3 months) in speech intelligibility.

Anticipated Course of Impairment The patient’s condition is ___________ in nature and __________ is expected to ____________. Therefore it is anticipated that the patient’s natural speech will not be sufficient to meet daily communication needs for ___________ Comprehensive Assessment Hearing Status The patient has _________ of hearing impairment. The patient’s __________ has _________ of hearing impairment. Informal observation of functional listening performance during the SGD assessment revealed the patient and/or caregiver required the following modifications regarding auditory output to use a SGD effectively.

Modification Patient CaregiverNo modifications Headphones Use of dual visual display to read messages Specific speech output options.

NAME: DATE OF EVALUATION: ADDRESS: DATE OF BIRTH: TELEPHONE: AGE: REFERRED BY: MEDICAL DIAGNOSIS: LICENSED SLP: SLP DIAGNOSIS: __________ DATE OF REPORT: DATE OF ONSET:

Name: 2. DOB:

With modifications as listed above, the patient demonstrates adequate hearing ability to use a SGD to communicate functionally. Visual Status The patient has a history of _________. The patient’s __________ has a history of _________. Informal observation of functional visual performance during the SGD assessment revealed the patient and/or caregiver required the following modifications to use a SGD effectively given current vision status.

Modification Patient Caregiver No modifications Font size used on SGD display and/or symbol labels (“gloss”) should be: ________

Picture-symbols and/or icons should be the following size: _______

A flat display is required to reduce visual tracking requirements (e.g., need to alternate focus between keyboard and display to monitor selections)

Color contrasts are needed to enhance text or symbol discrimination such as:

Number of items per display should be: Auditory feedback from device is needed to assist in message preparation/selection.

With modifications as listed above, the patient demonstrates the visual abilities to use a SGD to communicate functionally. Physical Status The patient was able to successfully access SGDs presented at the evaluation with the following selection technique/modifications. Check Selection Technique Type Additional Information

Manual direct selection ________ Optical Direct Selection High Tech Eye Gaze

Direct Selection

Scanning ________, _______

Morse Code _____ Requires access

modifications over time due to degenerative condition

The patient uses ________ for mobility. Therefore, a wheelchair mounting system __________ to transport the patient’s SGD.

Name: 3. DOB:

With the above modifications/considerations, the patient possesses the physical abilities to effectively use a SGD and required accessories to communicate. Language Skills The patient presents with _____ impairment in language functioning as it relates to using an appropriate SGD. Based on patient report and observation of the patient’s language and literacy skills during the evaluation, the patient possesses the following skills/abilities.

Skill/Ability Mastery Follows simple instructions (e.g., “Look at me.” “Turn your head.” “Open your mouth.”)

________

Follows complex instructions ________ Follows general conversation ________ Reads/comprehends common words ________ Reads/comprehends simple sentences ________ Reads comprehends short paragraphs ________ Reads the newspaper ________ Spells common words ________ Generates basic messages using writing/spelling skills ________ Generates complex messages using writing/spelling skills ________ Generates basic messages by using pictographic symbols ________ Generates complex messages using pictographic symbols ________ Generates messages using generative symbols (e.g., MinSpeak™)

________

Given the patient’s language/literacy functioning, a SGD that provides message production using _____________ will be required. Following _______ instruction, the patient demonstrated the linguistic capacity to generate ________ messages on an SGD with__________. The patient’s linguistic performance with the SGDs presented during the evaluation indicated the necessary language skills to functionally communicate using a SGD. Cognitive Skills The patient presents with ______ impairment in cognitive functioning as it relates to ability to use an appropriate SGD. The patient’s attention, memory and problem solving skills observed during the evaluation appeared functional to learn to use a SGD successfully. For example, during the _______ assessment/training trials, the patient demonstrated independence or progress in mastering the following SGD features.

Feature Mastery Turns SGD on and off ________ Navigates within and between display pages on a dynamic display SGD

________

Uses dictionary features to locate vocabulary not available on pre-programmed displays

________

Name: 4. DOB:

Uses word-prediction ________ Retrieves messages stored under letter codes or symbol codes ________ Stores messages under letter codes ________ Stores messages under picture symbols ________ Learns icon-code sequences to retrieve words on SGD (e.g., Unity™ Core)

________

Navigates within SGD “Menu” options to modify device options (e.g., voice, scan rate, feedback).

________

The patient demonstrates the necessary cognitive abilities (i.e., attention, memory, and problem-solving) skills to learn to use a SGD to achieve functional communication goals. III. DAILY COMMUNICATION NEEDS

Specific Daily Functional Communication Needs

The results of a communication needs interview conducted with the patient, relevant family members and caregivers revealed the following communication needs.

Communicative Activity.

Communication to:

Communication Partner(s)

Communicative Environment(s)

Is Need Met with Natural

Speech and/or Low Tech?

Express basic physical needs/wants.

spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger

home medical facility community support group work/school telephone

yes no

NA

Express needs/wants in emergences.



yes no

NA

Express detailed physical needs/wants.



yes no

NA

Name: 5. DOB: Participate in decision-making (e.g., discuss choices for end-of-life care).



yes no

NA

Participate in conversation.



yes no

NA

Tell personal stories and anecdotes.



yes no

NA

Report medical status and complaints.



yes no

NA

Ask questions. spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger


yes no

NA

Give responses. spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger


yes no

NA

Name: 6. DOB: spouse

immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger


yes no

NA



yes no

NA

Ability to Meet Communication Needs With Non-SGD Treatment Approaches

Speech therapy to improve/increase functional speech is not a viable option to meet the patient’s communication needs because:

The patient’s has a degenerative condition for which speech/language therapy is not effective.

The patient received speech/language treatment for with no significant changes in speech/language functioning.

The patient’s speech/language functioning has been static for and no improvement is expected.

The results of the communication needs assessment as documented in the previous section indicate the majority of patient’s daily functional communication needs cannot be met with natural speech and/or low tech communication devices. Therefore the patient requires a SGD to achieve and/or maintain functional communication ability in activities of daily living.

IV. FUNCTIONAL COMMUNICATION GOALS

The patient’s immediate, short term and long term goals and estimated times to completion following receipt of the recommended SGD are listed below.

Functional Communication Goals Patient will use SGD independently to:

Immediate Short Term

Long Term

Call for help from a spouse/caregiver in another room in emergency. _________

Contact a family member, friend or public agency for help on the

Name: 7. DOB: telephone in emergency. _________ Communicate physical needs and emotional status to spouse/caregiver on a daily basis, as needed. _________

Describe physical symptoms and ask any questions when interacting with physician and other health care professionals as needed. _________

Engage in social communication exchanges with immediate family members in person. _________

Engage in social communication exchanges with extended family members and friends by use of the telephone. _________

Engage in social communication exchanges with friends at their homes and in other community settings. _________

Use the telephone to make contact friends and extended family to interact socially. _________

Ask questions and provide responses in community-based transactions (e.g., ordering a meal in a restaurant, asking directions, etc.) _________

Instruct caregivers on the care requirements (e.g., transfers, bathing, moving from wheelchair to the car.) _________

Participate in family planning decisions (e.g., household management, finances, childrearing, etc.) _________

Participate in support groups. _________ _________ _________ _________

V. RATIONALE FOR DEVICE SELECTION

This individual requires a speech generating device with the following features to meet functional communication goals as stated in the previous section of this report.

Input Features/ Selection Technique

Check Selection Technique Type Rationale Manual direct selection _______ Optical Direct Selection High Tech Eye Gaze

Direct Selection

Scanning _______, _______

Morse Code _______ Provides multiple access

technique options to accommodate changing physical condition

Keyboard Dynamic display

Name: 8. DOB:

Message Characteristics/Features

Check Characteristic or Feature Rationale Message generation using spelling Message generation using a combination

of pre-programmed whole words and spelling

Message generation using pictographic symbols (e.g., PCS, Dynasyms, custom symbols)

Message generation using multi-meaning icon coding (e.g., MinSpeak™)

Message selection using photographs and/or tangible symbols

Ability to adjust font/symbol size to accommodate visual needs

Flat display to reduce visual tracking requirements

Ability to adjust color and contrasts to accommodate visual or cognitive needs

Ability to adjust number of items per display to accommodate visual, physical and/or cognitive needs

Ability to store/edit/retrieve whole messages under word/symbol buttons

Ability to store/edit/retrieve narrative messages (e.g., stories, reports, speeches) from message files

Provides word/symbol prediction rate acceleration techniques

Provides abbreviation expansion (letter coding) rate acceleration techniques

Output Features

Check Feature or Option Specifications if Applicable

Rationale

Synthesized speech Essential for: message generation using

spelling telephone non-reading partners

Name: 9. DOB:

visually impaired partners Digitized speech _______ Essential for:

telephone non-reading partners visually impaired partners

User display size _______ Dual display

(user/listener) Essential for:

hearing impaired partners noisy environments

Auditory feedback from device to assist in message preparation/selection

Other Features

Check Feature or Option Specifications if applicable

Rationale

Wheelchair mounting System

Small/lightweight for carrying by user

Length of use after battery charged

Display viewable in direct sunlight

Recommended Speech Generating Device Code

Based on the patient’s communication needs and considering the patient’s visual, hearing, physical, language and cognitive status as well as specified features as described in this report, SGDs in the ______ Medicare/CPT code category were evaluated to determine the most appropriate SGD to meet the patient’s functional communication goals.

Equipment and Procedures Used in Assessment Speech Generating Devices and Accessories Evaluated The following SGDs and accessories were presented for evaluation. Procedures Used in SGD Trials To assess the patient’s ability to use the selected SGDs the following procedures were used.

Name: 10. DOB:

Outcome of SGD Trials For the following reasons the was selected as the most appropriate SGD for the patient. The other SGDs evaluated were ruled out for the following reasons. Speech Generating Device and Accessories Recommended

The individual's ability to achieve functional communication goals requires the acquisition and use of the SGD, mounting/carrying devices and accessories listed below. This SGD represents the clinically most appropriate device for ( ).

SGD, Mounting System, or Accessory

Medicare/CPT Code

Manufacturer/Vendor

______ ______ ______ ______ ______ ______

Important: Contact family for specifications regarding tubing size for wheelchair mounting system.

Patient/Family Support of Speech Generating Device

The patient’s ________ was present at the evaluation. The ________ was supportive of the patient using the SGD and agreed to the necessity of the SGD for meeting the patient’s communicative needs in activities of daily living.

Physician Involvement Statement

This report was forwarded to the treating physician on . The physician was asked to write a prescription for the recommended SGD and accessories.

VI. TREATMENT PLAN

Following receipt of the recommended SGD and accessories, it is recommended the patient receive of treatment sessions addressing the acquisition of the functional communication goals described in part IV of this report. The patient’s family and/or primary caregivers are encouraged to participate in the treatment sessions so they may learn to assist the patient in the use of the SGD as needed. The patient’s treatment goals would best be met in ______ setting. Following discharge from treatment, the patient will be reevaluated as needed (at

Name: 11. DOB:

the request of the patient, physician, or family) to determine the need for updates/modifications of the SGD.

VII. SLP ASSURANCE OF FINANCIAL INDEPENDENCE AND SIGNATURE

The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of any SGD.

Evaluating SLP name: ASHA Certification #: State License #:

AAC Planning

Tools

Developed by Vicki Clarke, Dynamic Therapy Associates Inc.

AAC Intervention Planning: Schedules AAC User: Meeting Date: Implementation Date:

Type of Schedule: Typical Day Frequent Special Events Infrequent Important Events

Directions: 1st

Column: Write down all activities 2

nd Column: People, Place- Setting

3rd

-7th

Column: Check if activity meets these descriptions

8th

Column: Compare each activity with the others using columns 3-7 and prioritize by importance

9th

Column: List Vocabulary used in this activity- vocab for request, respond, comment,

Pri

ori

ty #

Activity

(ex: get dressed,

watch t.v., pack

backpack, circle time,

lunch...)

Partners/

Environment

(ex: Mom/Kitchen)

Rel

ate

d I

EP

Go

al

#

Incr

ease

s In

dep

end

ence

?

Mo

tiva

tin

g?

Fru

stra

tin

g?

So

cia

lly

Sig

nif

ican

t?

Vocabulary

(messages AAC user might use in this situation,

words needed)


Pri

ori

ty #

Activity Partners/

Environment

Rel

ate

d I

EP

Go

al

#

Incr

ease

s

Ind

epen

den

ce?

Mo

tiva

tin

g?

Fru

stra

tin

g?

So

cia

lly

Sig

nif

ican

t? Vocabulary


AAC Intervention Planning: Vocabulary Customization

AAC User: ____Meeting Date: __________Implementation Date:___________________

List AAC User’s commonly used vocabulary in categories.

Family & Friends Favorite Activities Favorite Characters Toys/Leisure Items


Foods & Drinks ID Info (age, birthday,

address, phone, school, how I

communicate)

Places I Go High Impact Msgs (check all needed)

All done

More

Change it

Something else

You do it

Let me

Like it

Don’t like it

Stop

Hi

Bye

What?

Where?

Wait


Notes:

aac evaluation tools - the georgia speech-language hearing ...€¦ · 2. speech and language...

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