Speech-Language/Audiology(Eval and Consult) Services Transaction Log

2016–2017 School Year

Only record for students for whom you provide IEP-ordered, health-related services.

Student Full LegalName: School/Contractor:

Student DOB: District of Liability:

For each date of service, check the service type, indicate the service code and record the number of minutes.

Date: 9/10/14 (example only)
 Eval □ Consult Code: 3 Code:
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Eval Code / Description / Consult Code / Description
E1 / Evaluation of Speech Fluency (e.g. stuttering, cluttering) / C1 / Consultation of Speech Fluency
E2 / Evaluation of Speech Sound production (e.g. articulation, phonological process, apraxia, dysarthia) / C2 / Consultation of Speech Sound production
E3 / Evaluation of Speech Sound production (e.g. articulation, phonological process, apraxia, dysarthia) with evaluation of language comprehension and expression (e.g. receptive and expressive language) / C3 / Consultation of Speech Sound production with consultation of language comprehension and expression
E4 / Behavioral and qualitative analysis of voice and resonance / C4 / Consultation of behavioral and qualitative analysis of voice andresonance
Unless so noted, school was in session and students were in attendance on all days recorded above. I have edited this form to correctly reflect services delivered on the above dates.
Practitioner Signature†: ______License/Certification/DOE Endorsement‡: ______ Date: ______
Practitioner Printed Name: ______

†Original, handwritten signature required ‡E.g. MS, CCC-SLP

MSB™ | 97 High Street | Somersworth, NH 03878

Revision Date: 8/23/2016