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Van Tatenhove, PA
Augmentative & Alternative Communication Specialist
Speech-Language Clinician, MS, CCC-SLP
Personal Information
Name of Person: Date of Birth: Sex:
Place of Residence: Primary Medical Diagnosis:
Address: Secondary Medical Diagnosis:
Home Telephone:
Work Telephone:
Email: Cell Phone:
Social Security #: Fax:
Insurance Carrier: Medicaid #:
Insurance ID #: Medicare #:
Insurance Sponsor: Insurance Phone #:
Advocate/Guardian: Telephone:
Address: Cell Phone:
Fax:
Email:
Assessment Information
Date(s) of Evaluation
Sessions:
Evaluation Site(s):
Evaluation Team
Members and Roles:
Pre-Assessment Activities
Send a pre-assessment form to key personnel who know and/or work with the
person. Review the pre-assessment information prior to any formal on-site
assessment activities.
Pre-Assessment Form Sent pediatric | adult congenital | adult
acquired
Sent To: Date Sent:
Address: Date Received Back:
Additional Information Received:
speech therapy report
occupational therapy
physical therapy report
educational report/IEP/support plan
video/photographs
Telephone: other
Assessment Interview
Conduct an interview with available family/caregivers/teachers to confirm
and/or clarify information from the pre-assessment form. Include the person
who needs AAC if appropriate. Complete any additional protocols, as needed.
Record the interview (with permission).
Confirm medical information:
Confirm perceptual information:
o hearing:
o vision:
o tactile/proprioceptive/motor:
o information processing:
Record current medications:
Confirm history of speech therapy intervention:
Confirm history of AAC system use:
Confirm current status of AAC system use:
Communication needs (attach form):
Additional protocols used:
o Social Networks: A Communication Inventory for Individuals with
Complex Communication Needs and their Communication Partners.
(Blackstone & Berg, Attainment Company)
o The AAC Profile: A Continuum of Learning (Kovach, LinguiSystems)
o The Communication Matrix (Rowland)
o Other:
Observation of the Person Who Needs AAC
If the assessment it being conducted at a natural setting for the person (e.g.,
home, classroom, worksite), observe the person prior to any formal on-site
assessment activities. Videotape the observation (with permission). Observe
for the following general areas and record key information:
1. Communication Partners (skilled, unskilled, effective, ineffective)
5. Language Abilities
6. Perceptual Skills
7. Physical Abilities
2. Hearing
a. What, if any, auditory factors needed to be evaluated as part of an AAC
assessment?
2. Accessing Activities
a. List any access protocols conducted (self-developed, protocols within
an AAC device or tablet/app).
Direct Selection via a mechanical tool (e.g., head stick, pointer stick,
etc.)
Scanning
o Number of switches:
o Type of switch(es):
o Location of switch(es:)
3. Describe any use of or need for Partner Assisted Scanning (with a device or
on a manual communication board).
4. Mounting on a Wheelchair
a. Brand of wheelchair:
b. Tube width/size:
c. Lap tray size:
d. Other:
5. Does the person drive a power wheelchair? yes |no If NO, is purchase of a
power wheelchair anticipated in the near future? yes | no
The person, with instruction, was able to retrieve core and extended
vocabulary using these vocabulary organizational paradigms. Provide
examples of language generated.
a. Semantic Compaction/Minspeak
locates icons on the main display by primary name (e.g., apple,
bed, juice, dice)
identifies a logical icon for a noun concept (e.g., food, furniture,
beverage, game)
identifies a logical icon for a verb concept (e.g., eat, sleep, drink,
play)
identifies a logical icon for an adjective concept (e.g., hungry,
tired, thirsty)
completes a two-part icon sequence using previously identified
icons
select vocabulary from an activity row (e.g., drinks, foods, toys)
produces a simple phrase (e.g., eat food, drink juice, play toys)
b. Page-Based Navigations
locates pictures on the main display by primary name
locates categorical pictures that navigate to other pages
identifies pictures on various pages
produces a simple phrase with words on 1 page
produces a simple phrase with words on 2 or more pages
c. Word Prediction
spells initial letters correctly
selects the correct word from a word prediction display
selects from grammatical prediction options
selects from predictive sentence building (predict next word in
sentence) options
3. Vocabulary Generation
The person, with instruction, was able to . (provide examples of
language generated):
4. What are your impressions of the persons ability to learn to use various
strategies for representing, organizing and retrieving vocabulary
independently. Address attention, learning style, short-term memory,
following sequences/navigations, etc.
5. What was observed in terms of the influence of motor planning and motor
automaticity in vocabulary retrieval and the generation of language?
Speech Skills
1. The person is aware when his/her speech is not understood? yes | no |
maybe | dont know
2. The person is showing signs of communication frustration when depending
on his/her speech to communicate? yes | no | maybe | dont know
Describe:
3. The person is intelligible .
a. to familiar people on a known topic usually | often |
sometimes | rarely
b. to familiar people on an unknown topic usually | often |
sometimes | rarely
c. to unfamiliar people on a known topic usually | often |
sometimes | rarely
5. If the person has some intelligible speech, describe WHY the person needs
an AAC system? Who wants the AAC system? When will it be used?
c. To confirm/deny (e.g., Did you like that? Is this what you wanted?)
10. Other:
List the aided AAC systems tried. Make sure you ethically consider
ALL of the major types of aided AAC systems, such manual
communication boards, Minspeak systems, page-based systems,
and mobile technologies/apps. Videotape ALL system trials, with
permission.
1.
2.
3.
4.
5.
b. Target vocabulary
d. Impressions
b. Target vocabulary
d. Impressions
b. Target vocabulary
d. Impressions
b. Target vocabulary
d. Impressions
b. Target vocabulary
d. Impressions
Teams Recommendations
1. AAC System
2. Vocabulary Program/App
3. Access Method
4. Transportation Method
5. Instructional Supports
2. The caregivers/family agree with the recommendation for the AAC system,
vocabulary program/app, access method, and transportation method. yes |
no Describe.
Next Steps (Discuss and list the next steps to be taken in order to
implement the recommendations.)