Teachers complete this checklist regarding students with communication and ​ overall learning concerns. Various outcomes include teacher education, short-term ​ speech and​ language interventions. A speech/language assessment or a ​comprehensive assessment may be warranted if external factors can be sufficiently ruled out.

This form includes three sections:

1) Description of the child’s communication (English or primary language) and behavior

2) External factors that may influence a child’s education (lack of exposure to rich language, status as an English learner, lack of exposure to literacy, limited peer interactions prior to preschool, family circumstances, frequent military deployment, etc.)

3) Follow-up steps and plan for addressing the areas of concern, which includes signatures from the teacher, site administrator, SLP and family member (if possible)