Teacher Checklist-Fluency

The child above has been referred for or is receiving services 
regarding fluency skills.  Please help me gain a better overall view of 
this student's speech skills by completing the following information:

Informational Checklists:

1. 	This student:  (Check all that apply)
	_______ doesn't mind talking in class.
	_______ seems to avoid speaking in class. (Does not volunteer, 
			if called upon, may frequently not reply)
	_______ speaks with little or no outward signs of frustration.
	_______ is difficult to understand in class.
	_______demonstrates frustration when speaking (please 
		describe): ______________________________
	_______ performs average or above average academically.

2. 	This student is disfluent or stutters when he/she:  (Check all 
	that apply)
	_______ begins the first word of a sentence.
	_______ speaks to the class.
	_______ speaks during an entire sentence.
	_______ gets upset.
	_______ uses little words. 
	_______ shares ideas or tells a story.
	_______ uses main words. 
	_______ answers questions.
	_______ talks with peers.
	_______ carries on a conversation.
	_______ gives messages. 
	_______ reads aloud.
	_______ talks to adults.
	_______ other ___________________________________________

3. 	Check any of the following behaviors you have noticed in 
	this child's speech: 
	_______ revisions (starting and stopping and starting over 
			again)
	_______ frequent interjections (um, like, you know)
	_______ word repetitions (we-we-we)
	_______ phrase repetitions (and then, and then)
	_______ part-word repetitions (ta-ta-take)
	_______ sound repetitions (t-t-t take)
	_______ prolongations (n--------obody)
	_______ block (noticeable tension/no speech comes out)
	_______ unusual face or body movements (visible tension, head 
			nods, eye movements)
	_______ abnormal breathing patterns
	_______ other ___________________________________________


In the Classroom: 

1. 	I do/do not have concerns about this child's speech because:

2. 	I observe the most disfluency when: 	

3. 	When this child has difficulty speaking he/she reacts by:.

4. 	When this child has difficulty speaking, I respond by:



Your Perceptions:

1.    I have/have not had prior experience with a child who stutters.
       
2.    I feel stuttering is caused by:

3.    Some questions I have about stuttering are:



4.    Some questions I have about helping this child be successful in 
	the classroom would be:


5.    The amount of knowledge I currently have regarding the 
       disorder of stuttering is:
	Nothing							         A Lot
  	    1 	    2	    3	    4	    5	    6	    7

6.    My confidence level regarding dealing with stuttering in the 
	classroom would be:
No confidence						         Very Confident
  	    1 	    2	    3	    4	    5	    6	    7

7.    My comfort level when communicating with this child is:
Uncomfortable 						         Very Comfortable
  	    1 	    2	    3	    4	    5	    6	    7

Your Observations:

This child with PEERS:

1.    Please describe this child's relationships with others of the same age.

2.    Has this student been teased or mimicked because of his/her speech?

3.    When this child has difficulty speaking, the other children react by:

4. 	Following a reaction by a peer, this child:

This child in GENERAL:

1. 	Have others students or this student's parent(s) ever mentions 
his/her fluency problems?  If yes, what was discussed?


2.    Has this student ever talked to you about his/her speech 
problem?  If yes, what was discussed?


3. 	What other information might be pertinent regarding this 
child's speech and language skills? 


4.    Do you have any other concerns regarding this child's speech and 
language, academic, or social skills?


Thank you for taking time to share this helpful information.   

Please return this form to _______________________________________by _____________
			Speech-Language Pathologist			Date