PERRY COUNTY PUBLIC SCHOOL DISTRICT
SPEECH / LANGUAGE CHECKLIST

Name: ______________________ School: ____________________ D.O.B.: ________

THE STUDENT SHOULD BE COMPARED TO HIS / HER PEER GROUP

SPEECH SOUND PRODUCTION and USE	

1. Does the child substitute one sound for another?			YES	NO
2. Does the child omit sounds?					YES	NO
3. Does the child distort sounds?					YES	NO
4. Is the child very hard to understand?				YES	NO

FLUENCY

1. Is the child disturbed by stuttering?				YES	NO
2. Does the child have difficulty in getting his / her words out?	YES	NO
3. Does the child repeat sounds of syllables or words more than
    his / her classmates:						YES	NO

VOICE

1. Is the child’s voice monotonous most of the time?		YES	NO
2. Is the child’s voice hoarse most of the time?			YES	NO
3. Is the child’s voice too loud most of the time?			YES	NO
4. Is the child’s voice difficult to hear in class most of the time?	YES	NO
5. Is the child’s voice too high or too low in comparison to 
    his / her peers?							YES	NO

EXPRESSIVE LANGUAGE / RECEPTIVE LANGUAGE

1. Does the child use shorter and simpler sentences than classmates? YES	NO
2. Does the child appear to understand oral directions as well as
    classmates?								 YES	NO
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A Referral to the speech / language pathologist for further evaluation 
is recommended:							 YES	NO

___________________________________	_____________________	__________
	      Signature					Title			    Date

___________________________________	_____________________	__________
   Supervisor’s Signature (if necessary)		Title			    Date