PRESCHOOL SPEECH/LANGUAGE TEACHER CHECKLIST

Child’s Name: First ______________________________ Last: ____________________________ DOB: _____ /_____ /_____

Home Language Child: ____________________________ Parent: ___________________________ Date: _____ /_____ /_____

Person Providing Home Language Information: ________________________________________________________________

Site: _____________________________ Teacher’s Name: __________________________________________________________

Please put an X for the item that best describes this child’s speech and language.

Expressive Language (Identify for both primary language and English)

Primary English
_____ _____ Child uses gestures or vocalizes (makes sounds) to make needs known.
_____ _____ Child puts words together to talk to get needs met.
Average number of words put together (circle): 1-2, 2-3, 3-4, or 4-5
_____ _____ Child has a limited vocabulary, uses primarily nouns.
_____ _____ Child has developmentally appropriate expressive language skills.

Play Skills
_____ Child prefers to play alone.
_____ Child plays with other children, but does not talk.
_____ Child plays with teachers, but not with other children.
_____ Child demonstrates developmentally appropriate play skills while interacting with
other children and teachers.

Articulation
Primary English
_____ _____ Parents report difficulty understanding child in home language.
_____ _____ Child is hard to understand much of the time.
_____ _____ Child has a repaired cleft palate or other medical condition related to
speech/language.
_____ _____ Child is understood most of the time.
_____ _____ Child has developmentally appropriate articulation skills.

Fluency (Speech Smoothness)

Primary English
_____ _____ Child has difficulty getting words out, e.g. repeats or prolongs the first sound/syllable
of a word.

5:1 Preschool Teacher Speech/Language Checklist/NHA/08-04-2011 Page 1 of 2

Other Factors
Please put an X on each line that describes this child’s situation. These factors may impact a child’s
development and performance in the classroom.

_____ Learning English

_____ Language practices of home/community
_____ Limited experiences with peers or other adults
_____ Family circumstances
_____ Frequent moves
_____ Military deployment
_____ Attendance
_____ Health issues
_____ First time exposure to books and classroom language
_____ Other _______________________________________________

Screening Passed Failed Date

Hearing ______ _____ __________
Vision ______ _____ __________
______________________________________________________________________________________

Follow-up Tasks
Please put an X next to each task after completion.

Consultation with Speech-Language Pathologist _____

Copy of form given to Speech-Language Pathologist _____
Original placed in Disabilities section of child’s file _____

Outcome (To be completed by the teacher and SLP)

Preschool teacher, parent/guardian and SLP agree to the following outcome.
Please put an X next to one outcome.

General Education ______

General Education with Individualized Language Interventions _____
Special Education Referral/Assessment _____

________________________________ ______________________________
Teacher signature SLP signature

________________________________ ______________________________
Date Date

________________________________ ______________________________
Site Supervisor signature Parent/Guardian signature

________________________________ ________________________________
Date Date

Parent/Guardian did not attend.

5:1 Preschool Teacher Speech/Language Checklist/NHA/08-04-2011 Page 2 of 2