COMMUNICATION SKILLS TEACHER CHECKLIST Student DOB Grade Teacher School Date Please check yes or no to each of the following statements: Articulation (Speech Production) Language Yes No The student’s speech contains speech Yes No The student has difficulty understanding/ sound errors that are not typical for following age-appropriate directions. his/her age and social/cultural background. Sounds in words may be Yes No The student has difficulty answering or omitted, distorted, or substituted. responding to age-appropriate questions and other verbal information. Yes No The student’s speech is consistently difficult to understand, especially when Yes No The student has difficulty answering the topic is not known. comprehension questions about age- Voice appropriate stories. Yes No The student’s voice sounds abnormal Yes No The student’s oral language skills appear to (i.e., hoarseness, harshness, breathiness, be at risk nasal, pitch deviations, or distracting (i.e., grammatical errors, difficulty sequencing loudness level) lasting 3 weeks or information, frequent inappropriate more. responses, difficulty selecting and using vocabulary).This may not apply to English language learners or those known to speak a Speech Fluency dialect of English. Yes No The student’s speech contains Yes No The student’s conversational skills dysfluencies (repetitions of words or appear to be at risk (i.e., turn-taking, staying hesitations) or an abnormal rate that on topic, initiating conversation). interferes with communication. Yes No The student appears to be frustrated when speaking. Please check one: The student’s communication skills appear to be acceptable and do not affect his/her educational progress at this time. The student’s communication skills appear to be at risk and may adversely affect his/her educational progress in a significant way. – Refer to School Speech-Language Pathologist.
Medicaid Eligibility: Yes No Referred: ST. LANDRY PARISH PUPIL APPRAISAL CENTER Yes No VISION REPORT FORM Wearing Glasses / Contacts Yes No Name: Date Screened: Homeroom Teacher: School: Grade: Age: INITIAL SCREENING REPORT I. ACUITY – FAR POINT – LENS LEVER AT “FAR” Test Result A Right Eye Left Eye Switch “Off” 20 / B Left Eye Right Eye Switch “Off” 20 / II. ACUITY – NEAR POINT – LENS LEVER AT “NEAR” Test Result A Right Eye Left Eye Switch “Off” 20 / B Left Eye Right Eye Switch “Off” 20 / III. RESCREENING – HOTV Test Result ROSENBAUM (NEAR) Test Result Right Eye 20 / Right Eye 20 / Left Eye 20 / Left Eye 20 / IV. ACUITY – FAR POINT – LENS LEVER AT “FAR” – PRE-K or K Test Result A Right Eye Left Eye Switch “Off” Manual Allen / Card Test B Left Eye Right Eye Switch “Off” Yes / No / V. ACUITY – NEAR POINT – LENS LEVER AT “NEAR” – PRE-K or K Test Result A Right Eye Left Eye Switch “Off” Manual Allen / Card Test B Left Eye Right Eye Switch “Off” Yes / No / VI. MUSCLE BALANCE TEST – FAR POINT – LENS LEVEL AT “FAR” Pass Fail (1) Red Dot - in Box A or B = PASS VII. MUSCLE BALANCE TEST – NEAR POINT – LENS LEVEL AT “NEAR” Pass Fail (1) Red Dot - in Box A or B = PASS (Perform either the 2 Muscle Balance Tests or Manual Muscle Balance Test) VIII. MANUAL MUSCLE BALANCE TEST (R.N. USE ONLY) Pass Fail Cover/Uncover Alternate Cover Versions – Tracking Near Point of Convergence Hirshberg Pupillary Reflex IX. COLOR BLINDNESS TEST Pass Fail 4 out of 6 = PASS Notes: Referral for Eye Examination –Paarents, teachers and Nurses Observations Nurse’s Signature Test Adminstrator