Instructions: This form contains an analysis of needs in communication so that you can begin an
effective speech communication program this semester. Complete the form by answering all the
questions honestly.
Student’s Name ______________________________________ Date ____________________________
Year _____________
Section __________________________
Family: What is your father’s first language?__________________________________________
Your mother’s? ____________________In what province were you reared? _______________________
_______________ What languages or dialects have you been exposed to? _________________________
Course: What English subjects have you taken up? _____________________________________
Write only those which you passed. ________________________________________________________
Have you had private lessons in speech? ____________________________________________________
Extemporaneous Speech: Have you made reports in other classes before you enrolled in this
class? _______________________________________________________________________________
How many times have you spoken before an audience? ________________________________________
Have you participated in speech contests? ___________________________________________________
In debating? _______________ Have you ever been a salesman, a leader, an officer in an organization, or
a person engaged in meeting and influencing people? (Specify) __________________________________
_______________________________ In what situations do you speak best?_______________________
In which most poorly? __________________________________________________________________
Do you wish to participate in the school’s extracurricular speech activities? ________________________
Interpretative Speech: Have you participated in oral reading contests? (Specify) ______________
Have you participated in other activities as a reader? __________________________________________
Do you wish to participate in oral reading recitals? ____________________________________________
Have you taken part in stage presentations? (Specify) _________________________________________
Do you wish to participate in dramatics? ____________________________________________________
Voice: Do you stutter? _____________ Do you lisp? ______________ Have you ever had a
deformity of mouth, nose, or throat that interfered with your speech? (Specify) _____________________
Do you often have to repeat to get people to understand you? __________ Underline any of the following
sounds with which you have difficulty: p, b, m, wh, w, f, v, th (soft), th (hard), t, d, n, s, z, sh, zh, ch, j, l ,
r, k, g, ng, y. Has any teacher helped you with these sounds?_______ Does your voice carry well?______
Do you think you have a weak voice? ________ Do you think the pitch of your voice is too high, too low,
or just right? (Specify) ________ Are you able to control or change your voice at will? _______________

Music: Do you sing? __________ Play an instrument? __________________________________
Can you tell when someone else is out of tune? ______________________________________________
Adjustment to Speech Situations: Do you thoroughly dislike to speak to an audience? __________
Describe your feelings when you speak: ____________________________________________________
a) I face the audience with confidence, enthusiasm, uncertainty, fear of being laughed at, fear of
forgetting. b) I feel at ease, tense, unstable. c) I am nervous, frightened, hesitant, unable to say what I
want to say. d) I frequently forget, cannot follow my notes. e) My knees, hands, shake; my breathing,
voice, is unnatural; my heart pounds, my mouth feels dry. f) These feelings continue throughout my
speech; they leave after I have talked for a time. g) I feel satisfied, relieved, when I have completed my
Do you worry a great deal in advance of the time you have to speak? Were you ever severely frightened
while speaking to an audience? __________________ Have you ever been made fun of or laughed at
because of your manner of speaking? ______________ Would it upset you to use gestures in a speech or
reading? _______________ With whom do you feel most comfortable? ___________________________
Are you troubled by criticism? ___________________ Do you make friends easily? _________________
Are you at ease when you converse with your friends? ___________ With new acquaintances? ________
VIII. General: Describe yourself by underlining the appropriate words in the following list: bold,
dependent, conservative, friendly, cautious, quick-tempered, lethargic, shy, self-conscious, sensitive,
stolid, suspicious, self-reliant, reclusive, timid, languid, aggressive, inhibited, moody
Do you recall embarrassing speaking experiences of any kind in your life? (Specify) _________________
What is your personal aim? ______________________________________________________________
What is your chief hobby? _______________________________________________________________
In what field is your chief reading interest? __________________________________________________
What outside activities are you engaged or interested in? ______________________________________
List the expectations you have from the course: ______________________________________________