AAC Assessment

Cloverleaf Local Schools

Augmentative & Alternative Communication

Assessment/ Evaluation

Student: Grade:
Completed by: Date:
Input from a Speech/Language Pathologist is strongly encouraged for completion of this section

Present Mode(s) of Communication: (check all that apply)

semi-intelligible speech
gestures

intelligible speech
pointing

single-word utterances
change of body position/

vocalizations breathing patterns

telegraphic word combinations
sign language

facial expressions
sign language approximation

eye gaze
communication boards/ pictures

writing
AAC device:

Other:

Primary Mode of Communication:

Is this mode of communication reliable for the student? Describe:

Prognosis for Speech:

Good
Guarded
Poor
Severely Limited

Expressive Language Level:

Description of capabilities:

Differences noted between listeners? Describe:

Receptive Language Level:

Description of capabilities:

See Also Reverse Side

Page 1 Revised 1/07

 AAC Assessment
Cloverleaf Local Schools

Interaction Levels/Skills: Circle most appropriate rating for each item

1 Always 2 Frequently 3 Occasionally 4 Seldom 5 Never

Demonstrates a desire to communicate? 1 2 3 4 5
Initiates interactions with adults? 1 2 3 4 5
Initiates interactions with peers? 1 2 3 4 5
Responds to adult interactions? 1 2 3 4 5
Responds to peer interactions? 1 2 3 4 5
Asks questions of others? 1 2 3 4 5
Attempts to repair communication breakdowns? 1 2 3 4 5

Functional Communication Needs: (check top 5 areas where present skills are inadequate)

gain attention
respond to questions

express basic needs/wants
ask questions

respond yes/no
give information

provide personal information
participate in class activities

express feelings
participate in community activities

participate in social rituals
participate in vocational activities

Other:
conversational interactions

Emotional Status (as it relates to communication):

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Potential as an Augmentative Communicator:
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History of AAC Usage: Please include any aided and unaided system(s)
System Length of Use Results Obtained

Page 2 Revised 1/07