Verification of Disability in the Education Adjustment Program Category of Speech Language Impairment
Education Adjustment Program – Verification of Disability
Cover Sheet & Checklist
Student: Click here to enter text. / School: Click here to enter text. / Year Level: Click here to enter text.
Disability Category: Speech Language Impairment
☐ / Initial Verification / (i.e. no previous verification)
☐ / Review / of an existing verification
☐ / Adding / a new category to an existing verification: / Adding / ☐HI / ☐PI / ☐VI / ☐SED
☐ / Removal / from an existing category: / Removing / ☐ASD / ☐HI / ☐ID / ☐PI / ☐SLI / ☐VI / ☐SED
☐ / Changing / from an existing category to a new category: / Change from / to SLI
☐ / Transferring / into the RI System from a Non-Catholic sector
Documentation Checklist: (All documents to be enclosed and ticked off by school to confirm inclusion in the submission.)
Process / School / RI Verifier / Comments
EAP Consent Form
(EAP 1 updated 2013)
EAP Verification Form
SLI (EAP 7 updated 2014)
PART A – Student Details
PART B – Evidence Supporting Verification
Criterion 1 –
Criterion 1.1 History spoken communication
Criterion 1.2 Language Assessment Scores
Criterion 1.3 Performance spoken communication
Criterion 1.4 Targeted interventions
Criterion 1.5 Psych educational Assessment
PART B –
Criterion 2
Educational impact and adjustments
PART B –
Profession Specific Quality Assurance
Consulting Speech Pathologist to sign
Consulting Guidance Counsellor/ Psychologist to sign
PART B – Verification Outcome
School to complete Student Details
Verifier to sign the outcome
PART C –
Principal Request/Signature
EAP Profile
Educational Planning Document (IEP, PLP, ISP) (or equivalent school planning doc.)
If Review – previous EAP
Confirmation Documentation
Required Documentation Attachments:
Current Speech Pathologist Report and assessment results
Current Guidance/Consulting Psychologist Report and – Psychoeducational assessment scoring pages
Audiological test results
School Work Samples
Any additional reports/assessments
Members of the school team complete this form collaboratively, ensuring that relevant personnel have been involved in the data gathering and decisions relating to the impairment and activity limitations and participation restrictions for this student.
The verification form in each of the EAP categories consists of the following sections which must be completed:· PART A Student Details
· PART B Evidence Supporting Verification of Disability
· PART C Principal Request for Verification of Disability
Two (2) copies of this form and required attachments (outlined in Part B) to be submitted to:
The RI EAP Verification Team at the RI Equity Network meeting
Part A: Student Details
Last Name / Click here to enter text. / Date of Birth / Click here to enter text.
First Name / Click here to enter text. / Gender / Click here to enter text.
School / Click here to enter text. / Year Level / Click here to enter text.
School Address / Click here to enter text. / School Phone / Click here to enter text.
Contact person in school for this verification / Position
Email Address / Phone
Existing Categories:
☐Nil / ☐ASD / ☐HI / ☐ID / ☐PI / ☐SLI / ☐VI
This verification request is for:
☐ / Initial Verification (i.e. no previous verifications)
☐ / Review of an existing verification
☐ / Adding a new category to an existing verification
☐ / Changing EAP Category
☐ / Removal from an existing category
☐ / Transferring into RI College from a non-Catholic sector
Part B: Evidence Supporting Verification of Disability in the Education Adjustment Program Category of Speech Language Impairment
Required Documentation
The following must be included:
☐ Current signed report from Speech-Language Pathologist
☐ Current signed report from Guidance Officer/Consulting Psychologist
☐ Evidence of audiological test results
☐ Analysis of speech language samples / school work samples as appropriate
☐ Relevant additional reports/assessments
Speech-Language Pathologist Proposal (to be signed by the consulting Speech-Language Pathologist):
☐ The information gathered by the school team on this form and in the related attachments MEETS the DETE criteria for the EAP category of Speech-Language Impairment.
☐ The information gathered by the school team on this form and in the related attachments DOES NOT MEET the DETE criteria for the EAP category of Speech-Language Impairment.
Contact Details:
Name of consulting Speech Language Pathologist: Click here to enter text.
Email: Click here to enter text. / Phone: Click here to enter text.
Signature: / Fax: Click here to enter text.
Name of consulting Psychologist / School Counsellor: Click here to enter text.
Email: Click here to enter text. / Phone: Click here to enter text.
Signature:
/ Fax: Click here to enter text.
Evidence Supporting Verification
Criterion 1: There is a severe ongoing primary spoken communication disorder.
Criterion 1.1 Evidence of an ongoing history of poor performance in spoken communication.
Background information (provide details as relevant):
Information may include medical history, developmental history, relevant family history, language background, ESL/NESB factors, other factors etc.
Previous standardised assessment of spoken communication (provide results as relevant):
Assessment tool / Date Administered / Area of language / Standard score / Percentile rank / Range (e.g. 90% confidence
nterval)
Comments on previous standardised assessment of spoken communication (include interpretations as relevant):
Previous non-standardised assessment details (provide details as relevant):
Criterion 1.2 Scores obtained from standardised, individually administered current assessment measures of spoken communication development are at least two standard deviations below the mean.
Current assessment (within 12 months of the verification request) (provide results as relevant):
Assessment tool / Date administered / Area of language / Standard score / Percentile rank / Range (e.g. 90% confidence interval)
☐ Results of standardised assessment are compromised by test conditions or other factors (comment below)
☐ Results of standardised assessment do not reflect the student's abilities in spoken communication (comment below)
☐ Standardised assessment is inappropriate for this student (comment below)
☐ This summary includes interpretation of assessment administered by another Speech-Language Pathologist (comment below)
☐ Analysis/interpretation of speech and/or language samples is provided to support standardised assessment results or to provide further information (comment below)
Interpretive comments (provide details as relevant):
Consider test conditions, behaviour, concentration, attention, memory, fatigue, health, reluctance, auditory processing, etc. Mention anything unusual about the results (e.g. spread of subtest scores or why a score may not have been calculated). Explain results if standardised tests do not assess the areas of difficulty in spoken communication. Outline reasons why standardised tests may not be appropriate for the student.
Current non-standardised assessment details (provide details as relevant):
Criterion 1.3 Description of student’s performance in spoken communication domains.
Criterion 1.4 Response to appropriately targeted intervention for identified spoken communication difficulties.
Language Comprehension (understanding others)
1.3) Description of student's day-to-day performance in spoken communication within the school environment.
1.4) Targeted interventions provided (including by whom, when and frequency) and outcomes achieved.
Speech Processing (difficulty in this area alone does not constitute SLI)
1.3) Description of student's day-to-day performance in spoken communication within the school environment
1.4) Targeted interventions provided (including by whom, when and frequency) and outcomes achieved.
Language Production (expressing self)
1.3) Description of student's day-to-day performance in spoken communication within the school environment
1.4) Targeted interventions provided (including by whom, when and frequency) and outcomes achieved.
Language Use (appropriate use of speaking for a range of purposes)
1.3) Description of student's day-to-day performance in spoken communication within the school environment
1.4) Targeted interventions provided (including by whom, when and frequency) and outcomes achieved.
Speech Production (including intelligibility ratings)
1.3) Description of student's day-to-day performance in spoken communication within the school environment
1.4) Targeted interventions provided (including by whom, when and frequency) and outcomes achieved.
Criterion 1.5 Evidence that the spoken communication disorder is distinguished from disorders of spoken communication that are attributable to:
• Cognitive functioning
• Socio-cultural factors
• Hearing Impairment
• Autism Spectrum Disorder / • Social-emotional factors
• Intellectual Impairment
• Physical Impairment
• Vision Impairment
Previous cognitive and adaptive behaviour assessment(information gathered by School Counsellor/Consulting Psychologist):
Test name / Date administered / Test administrator (name and position) / Overall result / Subscale scores / Range (95% confidence interval)
Current cognitive and adaptive behaviour assessment (information gathered by School Counsellor/Consulting Psychologist):
Test name / Date administered / Test admi
istrator (name and position) / Overall resu
t / Subscale scores / Range (95% confidence interval)
☐ Results of standardised assessment are compromised by test conditions or other factors (comment below)
☐ Results of standardised assessment do not reflect the student's abilities (comment below)
☐ Standardised assessment is inappropriate for this student (comment below)
Comment on assessment as relevant:
Summary of cognitive ability and interpretation of results (to be completed by School Counsellor/Consulting Psychologist)
NB: Where standardised assessment is inappropriate, also comment on how the team has determined that the spoken communication disorder is not accounted for by cognitive ability.
Hearing (Information collected by the school team):
☐ Hearing has been tested and is within the normal range (note details below)
☐ There is a hearing loss (and there is a mismatch between the audiological profile and the profile of spoken communication difficulties expected for that type of hearing loss) (note details below)
☐ The student has a history of conductive hearning loss – otitis media (note details below)
Rationale for excluding hearing as the primary cause of the identified spoken communication disorder
(e.g. dates of hearing test and results, otitis media and related treatments, hearing aid, audiologist reports, case history etc):
Social-emotional Factors:
Are there social-emotional factors that may impact on the student’s spoken communication or functioning at school?
☐ Yes (note details below)
☐ No
Rationale for excluding social-emotional factors as the primary cause for the identified spoken communication disorder and student’s functioning at school.
Socio-cultural Factors:
Is the student from a culturally and/or linguistically diverse background, including students from indigenous backgrounds?
☐ Yes (note details below)
☐ No
Cultural and linguistic background and considerations made in assessment and diagnosis of spoken communication disorder (e.g. home language, parents' skills in English, first language acquisition, age when exposed to English, language use survey, ESL support provided and progress/outcomes, and adjustments that have been made).
Proposal for Verification in the EAP Category of Speech Language Impairment
(To be completed by the consulting Speech-Language Pathologist)
Statement of Professional Reasoning
Briefly outline the reasoning and decision-making in determining that:
☐ There is a severe ongoing primary spoken communication disorder.
OR
☐ The information no longer meets the departmental criteria for the EAP category of SLI.
Criterion 2: The student’s identified level of functioning results in activity limitations and participation restrictions at school requiring significant education adjustments. This section is to be completed through a collaborative process which MUST include input from the student’s teacher/s.
Evidence of the educational impact of the identified impairment
The Prompts for SLI Criterion 2 Form can be used as a guide for the completion of this section
(http://education.qld.gov.au/students/disabilities/adjustment/verification/forms.html)
CURRICULUM
achieved curriculum / knowledge, functioning and understanding of the world / teaching strategies / resources / assessment/reporting
Describe the student’s functioning (activity limitations and participation restrictions) related to the speech language impairment:
Outline the associated significant education adjustments that are currently in place for this student:
COMMUNICATION
receptive / expressive / pragmatics (language use) / speech / specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the speech language impairment:
Outline the associated significant education adjustments that are currently in place for this student:
SOCIAL PARTICIPATION/EMOTIONAL WELLBEING
social/interaction skills / self-management strategies / individualised plans / use of social development resources / specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the speech language impairment:
Outline the associated significant education adjustments that are currently in place for this student:
LEARNING ENVIRONMENT/ACCESS
classroom and non-classroom environment / organisational skills / sensory needs / transition skills / specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the speech language impairment:
Outline the associated significant education adjustments that are currently in place for this student:
HEALTH AND PERSONAL CARE, SAFETY
health management / risk management / self-care skills / specialised self-care procedure / individualised plans / specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the speech language impairment:
Outline the associated significant education adjustments that are currently in place for this student:
Evidence Supporting Verification of Disability in the Education Adjustment Program Category of Speech Language Impairment
Student Name: Click here to enter text. / Date of Birth: Click here to enter text.
School: Click here to enter text. / Year Level: Click here to enter text.
Profession Specific Quality Assurance and Decision-Making (to be completed by the RI Verification Team)
The gathering and interpretation of data and other information related to the DETE criteria for the EAP disability category of SLI requires specialist knowledge and professional decision making. This section of the verification form is used by the RI Verification team consisting of a speech-language pathologist and guidance counsellor/psychologist who act in the capacity of professional supervisors for ensuring quality and consistency in monitoring the data gathering, professional interpretation and reporting processes across RI Colleges.
☐ Appropriate data and information have been reported as evidence related to the departmental criteria for the EAP category of SLI.
AND
☐ Appropriate data gathering, assessment, interpretation and reporting processes have been used in collecting the data andinformation provided as evidence related to the departmental criteria for the EAP category of SLI.
OR
☐ Further data gathering/information is recommended before submitting the verification request to the EAP Verification Team (see notes below).
Eligibility
☐ / The process indicated in the Religious Institute Colleges protocols has been followed and I confirm that this student meets DETE’s criteria for the category of Speech Language Impairment
Ineligibility
☐ / The process indicated in the Religious Institute Colleges protocols has been followed and I confirm that this student does not meet DETE’s criteria for the category of Speech Language Impairment
Comment:
Recommendation for review of eligibility: / Review required / ☐ / YES / ☐ / NO / Date: Click here to enter text.
Criterion 1 / ☐ / YES / ☐ / NO / Date: Click here to enter text.
Criterion 2 / ☐ / YES / ☐ / NO / Date: Click here to enter text.
Name of RI Speech Language Pathologist: / Name of RI School Counsellor / Psychologist:
Address: / Address:
Telephone contact: / Telephone contact:
Email contact: / Email contact:
Signed: Date: / Signed: Date:
Criterion 1: There is a severe ongoing primary spoken communication disorder.
Criterion 1.1 Evidence of an ongoing history of poor performance in spoken communication
Comments
Criterion 1.2 - Scores obtained from standardised, individually administered current assessment measures of spoken communication development are at least two standard deviations below the mean.
If the request for verification is in the area of speech only:Comments
Criterion 1.3 - Description of student’s performance in spoken communication domains
Comments
Criterion 1.4 - Response to appropriately targeted intervention for spoken communication difficulties
Comments
Criterion 1.5 - Evidence that the primary spoken communication disorder is distinguished from disorders of spoken communication that are attributable to: cognitive functioning, socio-cultural factors, Hearing Impairment, Autism Spectrum Disorder, Social Emotional Disorder, Intellectual Disability, Physical Impairment and Vision Impairment.Psychoeducational Assessment and Reporting
Cognitive Functioning
AND
Comments
Criterion 1.5 continued
Hearing
Social-emotional Factors
Socio-cultural Factors
If the student is from a culturally and linguistically diverse background:
Other impairments
Comments
Criterion 2: The identified severe ongoing primary spoken communication disorder results in activity limitations and participation restrictions for the student at school requiring significant education adjustments.
CommentsPart C: Principal Request for Verification of Disability in the Education Adjustment Program Category of Speech Language Impairment
Verification of disability in the EAP category of Speech Language Impairment according to DETE’s criteria is requested for the following student according to the details outlined in PART A and PART B of this report and the related attachments:
Student Name Click here to enter text. / Click here to enter text.
School Click here to enter text. / Date of Birth Click here to enter text. / Year Level Click here to enter text.
In making this request I have ensured that:
· the student is enrolled and attending the school
· discussions have been held with the parent and/or student regarding this verification and agreement to proceed has been reached
· agreement to proceed with verification in this category has been obtained from the parent
· appropriate personnel have been involved in data gathering and reporting
· processes are in place to support this student within the school
· all documents for verification are complete
· original EAP documentation is held in the student’s school file
· copies of relevant documents will be sent to the EAP Verification Team
Principal Name:
Principal Signature: / Date
Copyright in this work is owned by the State of Queensland (Acting through the Department of Education, Training and Employment) and has been adapted by Religious Institute Colleges with consent.