General Information: Person completing the form: Interview participants: Date of interview: Student initials: Reason for referral/AT Domain: Overview: This form is designed to help teams explore different aspects of a student’s symbolic communication. Symbolic communication includes the use of aided methods (e.g., communication book, communication device, etc.) and the use of some unaided methods such as ASL (American Sign Language), SEE (Signed Exact English), and/or conventional gestures that are easily understood by others (e.g., shaking head, “no”, waving for hello/goodbye, etc.). For students who use some speech, their spoken communication should also be recorded on this form. A note should be made to differentiate communication using speech and using AAC methods. For each area answer the questions and/or complete the table, indicating: The level of independence with the skill (Listed across the top of the columns: Solid, Stronger Emerging, Weaker Emerging, Not Yet in Repertoire, or Don’t Know). The type of communication (Write the appropriate letter code for the student’s current communication in the correlated level of independence column: SW=single words, P=phrases, SW/P=single words and phrases) NOTE: Be sure to review the example and description sheets before filling out this form. Notes/anecdotes about the student’s communication with a given communication function are encouraged and should be typed directly into the corresponding box on the form. SW = using single words P = using phrases SW/P = uses single words and phrases Requesting/Regulating: SOLID: uses skill independently* 80% of the time or more, across multiple activities, communication partners and settings. STRONGER EMERGING: uses skill independently* 50% to 80% of the time, across more than 1 activity, communication partner or setting. WEAKER EMERGING: uses skill independently in at least 25% of opportunities within a highly structured activity or activities. NOT YET IN REPERTOIRE: uses skill only when prompted or not at all. DON’T KNOW: person filling out form is not sure about the student’s use of this skill. Requests items Requests actions Requests recurrence and/or “more”
Requests assistance Requests information Requests clarification Expresses protest or resistance Disagrees Negotiates Advocates for self Directs others Labeling/Commenting: SOLID: uses skill independently* 80% of the time or more, across multiple activities, communication partners and settings. STRONGER EMERGING: uses skill independently* 50% to 80% of the time, across more than 1 activity, communication partner or setting. WEAKER EMERGING: uses skill independently in at least 25% of opportunities within a highly structured activity or activities. NOT YET IN REPERTOIRE: uses skill only when prompted or not at all. DON’T KNOW: person filling out form is not sure about the student’s use of this skill. Labels/comments with nouns Labels/comments with verbs Labels/comments with descriptors Comments spontaneously Informs about self (personal information, preferences) Informs about others (personal information, preferences) Expresses feelings/internal states Maintaining and Initiating Interactions SOLID: uses skill independently* 80% of the time or more, across multiple activities, communication partners and settings. STRONGER EMERGING: uses skill independently* 50% to 80% of the time, across more than 1 activity, communication partner or setting. WEAKER EMERGING: uses skill independently in at least 25% of opportunities within a highly structured activity or activities. NOT YET IN REPERTOIRE: uses skill only when prompted or not at all. DON’T KNOW: person filling out form is not sure about the student’s use of this skill. Reciprocates greeting and/or farewell Initiates greeting and/or farewell Gains attention of others