VOICE IMPACT ON EDUCATIONAL PERFORMANCE QUESTIONNAIRE

Date
Dear Teacher,
Your student

has been referred for an evaluation of voiceis receiving a re-evaluation to review progress.

Your impression of the student’s communication in the classroom is essential in the evaluation process. The following checklist reviews many voice characteristics considered important for communicating effectively. Please complete this checklist by responding to each question and providing specific examples when possible. Using this information as a guide, please respond to the question on the back regarding the impact of the student’s voice on his/her ability to learn, contribute, and maintain positive/appropriate relationships. If you feel there are additional behaviors that the student exhibits or fails to demonstrate that are not covered on this form, please note these on the back. This information will contribute to a determination of eligibility for services and is needed by

. Please let me know if you have any questions or concerns. Thank you for your help.

______

Speech/Language Pathologist

Please respond to the following by using:

F = Frequently(> 50% of the time);

S = Sometimes (50 to 25% of the time)

R = Rarely(< 25% of the time);
NO = Not Observed / F / S / R / NO
1. Voice Characteristics

The student’s voice:

a. sounds different from his/her peers.
b. sounds too loud
c. sounds too soft
d. is hoarse
e. is too high pitched
f. is too low pitched
During the school day:
g. the student loses his/her voice. If so, when:
h. the student’s vocal quality sounds worse during particular times of the
day. If so, when:
i. the student does not speak loudly enough to be heard adequately in the classroom
j. the student does not speak loudly enough to be heard adequately in larger environments (e.g., gym, cafeteria, outside, etc.)
The student engages in excessive:
k. shouting/yelling
l. throat clearing
m coughing
n. animal / motor noises
On an everyday basis, the student’s voice sounds:
o. hypernasal (“talking through the nose”)
p. hyponasal (“stuffed up”)

Please respond to the following by using:

F = Frequently(> 50% of the time);

S = Sometimes (50 to 25% of the time)

R = Rarely(< 25% of the time);
NO = Not Observed / F / S / R / Page 2
NO
Does the student tend to have:
q. allergies
r. colds
s. ear infections
t. difficulty breathing through their nose (e.g., breathes predominantly through his/her mouth)
2. Communicating with others

The student’s voice:

a. makes his/her speech difficult to understand
b. distracts the listener from the content of the message.
Staff members and/or other children:
c. comment on the student’s speech
d. tease the student about his/her voice
e. avoid interactions with the student
3. Emotional Reactions

The student:

a. seems aware of his/her unusual voice quality
b. avoids talking in class discussions
c. avoids reading out loud

4. Current levels of academic performance

Subject / Current Grade / Other available assessment results (ILA, running records, quarterly assessments, MSA, HSA, etc.)
Reading / Language Arts
Written Language
Math
Science
Social Studies
Other

5. Based on your overall review of these behaviors, does the student’s voice affect his/her educational performance? no yes (if yes, describe how giving specific examples)

6. Comments / Examples: Please provide specific examples regarding the impact of the student’s voice on his/her ability to learn, contribute, maintain positive relationships (attach additional sheets or sample work as needed)

Teacher’s Signature ______Date ______

(Revised 8/07)