evaluations, peripheral speech mechanism and muscle ... · defects of articulation language...
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ED 027 686 EC 003 748By-MacLearie, Elizabeth C.Basic Record and Report Forms for Speech and Hearing Programs in Ohio.Ohio State Dept. of Education, Columbus. Div. of Special Education.Pub Date 67Note- 23p.EDRS Price MF-$0.25 HC-$1.25Descriptors-*Administration, Case Records, Conferences, Equipment, *Exceptional Child Education, Facilities,Hearing Therapists, Medical Evaluation, *Records (Forms), School Services, School Surveys, Speech Evaluation,Speech Therapists, *Speech Therapy, *State Programs, Student Evaluation
Identifiers- OhioRecord and report forms for speech and hearing programs in Ohio are provided
for the following areas: speech evaluation (including the articulation test, audiometricevaluations, peripheral speech mechanism and muscle coordination, voice, skill ofexpression, c!assification of speech problem, related data, and remarks andrecommendations); otorhinolaryngologist's report; report of larvngoscopy; speechtherapy log; conference report; and final case summary. Also included are forms forspace and equipment inventory, results of speech survey within the school, report ofcoordination activities, periodic report to superintendent, semi-annual progressreport to the superintendent, teacher request for speech and hearing evaluation,report of the evaluation, classroom teacher's evaluation of speech progress, andperiodic report to parents. A long case history form is not offered, but left to thespeech therapist to develop. A bibliography cites six guides or texts for therapistsand five diagnostic tests. (JD)
BASIC RECORD AND REPORT FORMS
FOR
SPEECH AND HEARING PROGRAMS IN OHIO
\
....S.........................."-
Issued by
Martin EssexSuperintendent of Public Instruction
OHIO DEPARTMENT OF EDUCATIONCOLUMBUS, OHIO
1 9 6 7
BASIC RECORD AND REPORT FORMS
FOR
SPEECH AND HEARING PROGRAMS IN OHIO
Prepared by
Elizabeth C. MacLearieEducational Consultant
Speecil and Hearing Therapy
WAYNE M. CARLEAssistant Superintendent of Public Instruction
S. I. BONHAM, JR DirectorDivision of Special Education
OHIO DEPARTMENT OF EDUCATIONCOLUMBUS, OHIO
1 9 6 7
U.S. DEPARTMENT OF HEALTH, EDUCATION & WELFARE
OFFICE OF EDUCATION
THIS DOCUMENT HAS BEEN REPRODUCED EXACTLY AS RECEIVED FROM THE
PERSON OR ORGANIZATION ORIGINATING IT. POINTS OF VIEW OR OPINIONS
STATED DO NOT NECESSARILY REPRESENT OFFICIAL OFFICE OF EDUCATION
POSITION OR POLICY.
PUBLIC SCHOOLS
SPEECH EVALUATION
Name Birthdate Age. Sex
School Grade Room
Parent or Guardian Address Telephone
Father's Occupation Mother's Occupation
I. Artiaulation Test Date: Examiner
Other:Type of Test: Picture Sentence
Consonants: IMF Comments Blends: Comments Comments
m bl sn
b fl sp
P gl st
w kl sw
h P1 gz
n sl ks
t spl dw
d dl kwk tl Vowels:
g i(eat)
3J
_3/brdr
I(sit)E (ten)
fv
frgr h a t )z e CcupA
1) kr a. (far)
5 pr IP (top)1 shr (ball)
8 skr Mook)
4 sprstr
u(moon)ju(new)
s tr (nose)r thr u(cow)t) sk ez(cake)
d3 skw ai(tie)hw sm 1/(boy)
Note: Consonants listed in usual order of development according to West,Ansberry, Carr, Rehabilitation of Speech (third edition p. 60), Harperand Brothers, 1957.
Key: Record substitution errors with sounds substitute. Mark omission(-); Distortion (Dis.); Inconsistent (Inc.). Circle sounds when theyare corrected.
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II. Audiometric Evaluations:
Dates:
Results: Is hearing normal? Yes ; No
III. Peripheral Speech Nechanism and Muscle Coordination: (check oneon each line)
Lips: normal ; cleft ; mobility
Teeth: normal ; maligned ; spaced ; missing ; false ;
malformed ; supernumerary
Jaw: normal ; open bite ; over bite ; under bite ;
cross bite ; mobility
Tongue: normal ; large ; small ; asymmetrical ;
mobility
Hard Palate: normal ; cleft ; repaired ;
contour: flat ; deep and narrow
Soft Palate: normal ; cleft ; repaired ; asymmetrical ;
mobility
Nasal Cavities: normal ; septum: deviated ; nasal occlusion:
right ; left ; nares constriction
Breathing: normal ; uneven ; deep ; shallow ; rapid
General Mobility of Oral Structures:
IV. Voice: (check one in each line)
Quality: normal ; hoarse ; harsh ; breathy ; nasal
denasal
Pitch: normal ; too high ; too law ; monotone ;
Pitch variability: adequate ; inadequate
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Intensity: normal ; too laud ; too soft ; uncontrolled
Variability: adequate ; inadequate
Rate: normal ; too rapid. ; too slow ; uneven ;
monotonous
V. Skill (If Expression:
General conversational speech:
Oral reading:
Expressive ability:
Receptive ability:
Speech adequacy:
VI. Classification of Speech Problem:
Articulatory Cerebral Palsy
Language Disorders Voice Disorder
Rhythm Disorders Impaired Hearing
Cleft Palate and/or Lip
Previous Speech Therapy:
Dates:
Results:
Speech Recordings Available?
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VII. Related Data:
A. Defects of Viion:
.1010.B. School Achievement: Slow Learner ; Below average
Average ; Above average ; Grades repeated
C. Name of Tests Given: (give dates and scores)
D. Gross Motor Coordination:
E. Fine Motor Coordination:
VIII. Remarks and Recommendations:
Name of child:
OTORHINOLARYNGOLOGIST'S REPORT
Address:treet
History of ear problem:
Age, Parent:
City Zip Code
Ear, Nose and Throat Examination:
Diagnosis:
Prognosis: Stationary Will Improve Progressive
Was audiometric evaluation given? Result:
Medical Recommendation: Alks..
Should hearing aid evaluation be considered?
Please return to:
Title: Address:
M.D.
Address: Date of Examination:
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Address:
Name of Child:
Date of Examination:
SrEreTE'
Age:
Type:
Parent:
16"117-123-77.P°e
REPORT OF LARYNGOSCOPY
General Health and Appearance:
Diagnosis:
Prognosis:
Medical Recammendation:
Should speech therapy be considered?
Do you recommend periodic checks? When?
SNOW
Please return t :
Title:
Address:
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M.D.
Address:
Date of this report:
NAma:
SCHOOIS
SPEECH THERAPY LOG
Classification of speech problem:
Working on:
Date:
Date:
Date: ........
Date:
Date:
Par tic ipants
SCHOOLS
Speech and Hearing Therapy
CONFERENCE REPORT
Type: Telephone ; School ; Home
Initia ted by:
Purpose:
Comments concerning the Interview:
11.1=1.0111
Speech and Hearing Therapist
Date
8
Name:
SCHOOLS
FINAL CASE SUMMARY
School: Grade:
Classification of Speech Problem:
Hearing: Normal Recheck Referred Under Treatment
Comments:
Voice:
Fluency:
Language Usage:
Number of Parent Conferences: Telephone Home School
Number of Conferences with: Teachers ; P''ncipal ; Nurse
Psychologist ; Other:
Cooperation of Child: Cooperative Indifferent Uncooperative
Cooperation of Parents: Cooperative Indifferent Uncooperative
Attendance: Possible Days Days Present Days Absent
Summary of Treatment: Number of Individual Sessions
Number of Group Sessions
Recommendations:
Results:
Dismiss ; Recheck ; Retain
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Speech and Hearing Therapist
a e
PUBLIC SCHOOLS
Space and Equipment Inventoryfor
Speech and Hearing Therapy
Name of School Principal
Location of room to be used Size
Will room be shared? No ; Yes ; If so, by Wbom
Days room is available A. M. Mon. Tues. Wed. Thurs. Fri.
(Circle) P. M. Mon. Tues. Wed. Thurs. Fri.
Are there interruptions? Explain
Is room quiet? Explain
Minimum equipment required under State Board of Education Standards:
5 Intermediate chairs (15-16 inch)
1 Intermediate height table to fit chairs
Therapist's Desk
Therapist's Chair
Bulletin Board ; Chalkboard ; Nirror
Filing Cabinet ; Tape Recorder
Size
Satisfactory Unsatisfactory Needs Improvementas Follows:
Lighting
Ventilation
Heatin&
Electrical Outlet
Acoustics ,
Comments:
---gpeec an Hear 1.'F-.--a----7Errer.st
Approved for Service: By Date
(Superintendent or coordinator of Speech TheriN-Program)
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SCHOOLS
1..itaaLl_af.121.122LIEME
Principal
School
On , a speech survey was made. The following is
a statistical account of the findings:
Number of childrenseen in survey
Number of children Mild Moderate Severe
with speech problems
Number enrolled inspeech therapy
Distribution of children enrolled in speech therapy classes according
to grade and type of problem:
Problem 1st 2nd 3rd 4th 5th 6th TOTAL
1. Articulation
2. Stuttering
3. Voice Disorders
4. LanguageDisorders
5. Cleft Palate
6. Cerebral Palsy
7. Hearing Impaired
---5iich and Hearing Therapist
Date of this report:
11.
SCHOOLS
Speech and Hearing Services
REPORT OF COORDINATION ACTIVITIES
Month
First Week:
Second Week:
Third Week:
Fourth Week:
12
---8peech i--lrng FligT'oist
Date of report:
Therapis :
SCHOOLS
Periodic Report to SuperintendentSpeech and Hearing Services
Date:
SCHOOLS
Screened forSeech
Screened forHearin:
Threshold Tests
Need Therapy
Speech TherapyEnrollment
SpeechreadingEnrollment
On Waiting List
Corrected
Dismissed
Improved
No Improvement
ParentConferencesTelephone Calls
to Parents
Home Visits
Classes Visitedby Therapist
Neetings or Conventions attended:
13
SCHOOLS
Speech and Hearing Therapy
Semi-Annual Progress Report to the Superintendent
NAME OF SCHOOL
NUMBER SCREENED FOR SPEECH
NUMBER NEEDING THERAPY (4nrolulas nase load)
NUMBER ENROLLED:
Defects of Articulation
Language Disorders
Stuttering
Cleft Palate
Cerebral Palsy
Voice Disorders
Hearing Impaired
NUMBER ON WAITING LIST: Mild Moderate Severe Total
PROGRESS OF THERAPY:
CorrectedWilIMM4.111M8
Improved
No Improvement
Dropped or Transferred
Retained
RELATED DATA:
Medical Referrals
Psychological Referrals
Home Visits
Parent Conferences at School
OBSERVATIONS OF CLINICAL WORK BY:
Administrator
Parents or GuardiansGINN
Others
114
Talks at Meetings
Teacher Conferences
Telephone Conferences
Speech and Hearing Therapist
Date
SCHOOLS
REQUEST FOR SPEECH AND HEARING EVALUATION
Name of Child: Age: Grade:
My interpretati7 of the speech and/or hearing problem:
=11111M,
.1NOMINIMIVOA. .31111=0111111
Check other significant information:
Poor reader
Avoids speaking in class
Appears tense and nervous
Inattentive in class discussions
Discipline problem
15
Teacher:
School:
Date:
Room
To:
SCHOOLS
REPORT OF SPEECH AND HEARING EVALUATION
School
From:
Results of Speech Evaluation:
Regarding
Grade:
Result of Hearing Evaluation:
Suggested procedures for classroom teacher:
Recommendations:
Therapy recommendedTherapy nowWaiting ListNo Therapy recommended
Thank you for referring this child.
16
Date
Child's Name:
Grade:
SCHOC1S
CLASSROOM TEACHER'S EVALUATION OF
SPEECH PROGRESS
Current Problem:
Teacher's Name:
Room Please return to the speechtherapist by
Improvement of speech when reading: Speaking:
1. No improvement 1. No improvement
2. Slight improvement 2, Slight improvement
3. Considerable improvement 3. Considerable improvement
4 Inconsistent 4 Inconsistent
5. Other 5. Other
Remarks:
/1.1111MME.... 11M17111MMINMINI
Signed:
Date:
SCHOOL
PERIODIC REPORT TO PARENTS
Dear
has attended speech class from
to .IIMINNIIMMILIMIllawl
We have been working on:
Your child hasAas not attended speech class regularly,
Progress in the above mentioned work has been:
Very satisfactory
Satisfactory
Fair
Slight _
Co-operation has been:
Very good
Good
Fair
Poor
Suggestions for you:
, Speech and Hearing Theraplst
Date
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LONG CASE BISTORY FORM
When minimum basic records are kept current, a long case
history form is not practical for every child enrolled in
public school speech therapy. For children with multiple or
severe problems, or for making referrals to other services,
additional information should be summarized on a long case
history form.
Since speech therapists have had experience in their
university preparation with this type of form, they may prefer
to develop their own form.
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BIBLTDGRAPHY
Basic Records and Re orts for Public School S beech and Hearin
proamms. State of Iowa, Department of Public Instruction,
1963.
Black, Martha E. Suech Correction in the Schools. Prentice-Hall,
Inc. Englewood Cliffs, New Jersey. 1964
Darley, Frederick L. Diagnosis andAysraisal of Communication
Disorders. Prentice-Hall, Englewood Cliffs, New Jersey. 1964
Irwin, Ruth B. Speech and Hearing Therapy (Textbook for Public
School Speech Clinicians). Stanwix House, Pittsburgh 4,
Pennsylvania. 1965
Johnson, Wendell; Darley, Frederick; Spriestersbach, D. C.
piaanosticitehecla_ialosslippthology. Harper and Row,
Publishers, Inc., 49 East 33rd Street, New York 16, New
York. 1963
Nelson, Severina; Johnson, Frances; Bounds, Sue. Reminders: A
Guide For S eech Correctionists in the State of Illinois.
Braun-Brumfield, Inc. Ann Arbor, Michigan. 1956
20
BIBLIOGRAPHY
Books
Basic Records and Re orts for Public School S-)eech and Hearin,otate of Iowa, Department of-PED ic Instrition.
Black, Martha E. S eech Correction in the Schools. Prentice-Hall,Inc., Englewood 011ff s, New Jersey.
Darley, Frederick L. Diacfnosis and AD raisal of CommunicationDisorders. Prentice-Hall, EnIewood
Irwin, Ruth B. Speech and Hearinr Thera N (Textbool: for PublicSchool Speech-Clinicians ). Stanwix House, Pittsburgh 4,Pennsylvania. 1965
Johnson, 'Wendell; Darley, Frederick; Spriestersbach, D. C.Diasnostic Methods in S eech Patholo 70 Harper and Row,Publishers, Iñ,49 East 33rdtriet, New York 16, New York./03Form from this text may be ordered from The InterstatePrinters and Publishers, 19-27 North Jackson Street,Danville, Illinois 61832. 5 each, compact set $1.28
Nelson, Severina; Johnson, Frances; Bounds, Sue. Reminders: AGuide For Sveech Correctionists in the State of-Illinois.Braun-Brumfield , Inc . , A-rii-77757F7TICEIgTh
1141.222Ii9_1!RIA
Barker, Janet (University of Arizona) and England, Gene.A Numerical Measure of Articulation: Further Develo ments.
McDonald, E. T. A Dee :Lest of Articulation. Stanwix House,Pittsburgh 4, ennsy
Meecham, Merlin. Verbal Lan ua e Develo ment Scale: A Measureof Language Age;--N5Fige irt to age t5 .
paid wath manual .55. American Guidance Service, Inc.,Publishers' Building, Circle Pines,Minnesota 55014.
Myklebust, Helmer R. Develo ment and Disorders of WrittenLanguage Volume I:-Victure tory'rEFITEETOF-TaT. Grum andStratton, 381 Park Avenue, South, New York, New York 10016$7.25. 1966
Templin, Mildred and Darley, Frederick. The Tem.Q1in-Darley Testsof Articulation. Bureau of Educational Research and Service,Extension Division, State University of Iowa, lowa City,Iowa. 1960
21