Worksheet 1 (Page 1 of 2)

COMMUNICATION PLAN WORKSHEET FOR STUDENT WHO IS DEAF OR HARD OF HEARING

Student: Student Name DOB: 00 / 00 / 000
S!"##$: S!"##$ Name G%ade: G%ade
P%&ma%' A%ea #( E$&)&*&$&t': Se!#nda%' A%ea+,- #( E$&)&*&$&t': +&( a..$&!a*$e-
Date #( IEP meet&n) /"en C#mmun&!at&#n P$an W#%0,"eet /a, !#m.$eted: 00 / 00 / 0001
I1 CONSIDER THE STUDENT2S LANGUAGE AND COMMUNICATION NEEDS1
31 T"e ,tudent2, .%&ma%' $an)ua)e &, #ne #% m#%e #( t"e (#$$#/&n) +!"e!0 a$$ t"at a..$'-:
Receptive Expressive
English
American Sign Language
ative language
1 T"e ,tudent2, .%&ma%' !#mmun&!at&#n m#de &, #ne #% m#%e #( t"e (#$$#/&n) +!"e!0 a$$ t"at a..$'-:
Receptive
Au!itor" #onceptual signs (e$g$ American Sign Language% Pi!gin Signe! English (PSE) also referre! to as #ASE)
English signs (e$g$ &anuall" #o!e! English such as Signe! English or Signing Exact English)
'ingerspelling (estures Speechrea!ing )actile #ue! Speech
*ther% please explain+
Expressive
#onceptual signs ,e$g$ American Sign Language% Pi!gin Signe! English (PSE) also referre! to as #onceptuall" Accurate
Signe! English (#ASE)-
English signs (e$g$ &anuall" #o!e! English such as Signe! English or Signing Exact English)
'ingerspelling (estures Speechrea!ing )actile #ue! Speech
*ther% please explain+
.$ What language(s) an! mo!e(s) of communication !o the parents use /ith their chil!0 What mo!es !oes the chil! use /ith
peers0

1$ #omments (optional)+
II1 CONSIDER OPPORTUNITIES FOR DIRECT COMMUNICATIONS WITH PEERS AND PROFESSIONAL
PERSONNEL AND OPPORTUNITIES FOR INSTRUCTION IN THE CHILD2S LANGUAGE AND
COMMUNICATION NEEDS1
1$ 2escri3e opportunities for !irect communication /ith peers$

2$ 2escri3e opportunities for !irect communication /ith professional staff an! other school personnel$

.$ 2escri3e opportunities for !irect instruction$

2irect language4communication4instruction occurs person to person% not through an a!!itional source (e$g$% e!ucational
interpreter% captioner$ )hese social% emotional an! aca!emic opportunities ma" 3e provi!e! 3" the school or famil"$)
'inal 1567
A!apte! from 8#ommunication #onsi!erations for Stu!ents /ho are 2eaf or 9ar! of 9earing%: e/ &exico% 8;EP #ommunication Plan for Stu!ents Who Are 2eaf or
9ar! of 9earing%: ;o/a an! 8#ommunication Plan for #hil!4Stu!ent Who is 2eaf49ar! of 9earing%: #olora!o$
Worksheet 1 (Page 1 of 2)
C#mmun&!at&#n P$an W#%0,"eet (#% Student W"# I, Dea( #% Ha%d #( Hea%&n)
Student: Student Name DOB: 00 / 00 / 000
S!"##$: S!"##$ Name G%ade: G%ade
III1 CONSIDER ACADEMIC LE4EL1
1$ 2oes the stu!ent have the communication an! language necessar" to ac<uire gra!e5level aca!emic skills an! concepts in the
general e!ucation curriculum0 =es o
;f "es% /hat supports are nee!e! to continue proficienc" in gra!e5level aca!emic skills an! concepts of the general e!ucation
curriculum0

;f no% /hat supports are nee!e! to increase the stu!ent>s proficienc" in his4her language an! communication to ac<uire gra!e5
level aca!emic skills an! concepts of the general e!ucation curriculum0

I41 CONSIDER FULL RANGE OF NEEDS1
1$ 2oes the chil! have access to all e!ucational components of the school (regular e!ucation classes% relate! services% gui!ance
counseling% recess% lunch% assem3lies% extra curricular activities% etc$)0 ;f not% /hat supports are nee!e! to allo/ for access0

2$ Are a!ult language mo!els availa3le /ho communicate in the stu!ent>s language4communication mo!e0

.$ What accommo!ations4mo!ifications are 3eing provi!e!0 What a!!itional accommo!ations4mo!ifications /ere consi!ere!0

41 CONSIDER AMPLIFICATION NEEDS1
Personal hearing !evices (hearing ai!% cochlear implant% tactile !evice)
Personal '& s"stem
'& s"stem4au!itor" trainer (/4o personal hearing !evice)
Soun!fiel! s"stem
o Amplification nee!e!
Place #omplete! Worksheet in E# 'ol!er
'inal 1567
A!apte! from 8#ommunication #onsi!erations for Stu!ents /ho are 2eaf or 9ar! of 9earing%: e/ &exico% 8;EP #ommunication Plan for Stu!ents Who Are 2eaf or
9ar! of 9earing%: ;o/a an! 8#ommunication Plan for #hil!4Stu!ent Who is 2eaf49ar! of 9earing%: #olora!o$