6057 rf text v3 reb1

RECORD FORMYear Month Day

Date of Assessment

Date of Birth

Chronological Age

Notes/Comments

Copyright © 2001 by NCS Pearson, Inc. All rights reserved.Warning: No part of this publication may be reproduced or transmitted in any form or by any means,electronic or mechanical, including photocopy, recording, or any information storage and retrieval system,without permission in writing from the copyright owner.Pearson is a trademark, in the U.S. and/or other countries, of Pearson Education, Inc., or its affiliate(s).Printed in the United States of America.

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Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Gender _ _ _ _ _ _ _ _

School _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Grade _ _ _ _ _ _ _ _ _ _ _ _

Classroom Teacher _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Examiner_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Summary ScoresPhonological Probe � Pass � Fail

Probe Criterion At/Above BelowScore Score Criterion Criterion

Third Person Singular

Past Tense

Be/Do (Be)

Be/Do (Do)

Sum of Probe Scores

Elicited Grammar Composite

Supplemental ProbeA' Criterion At/Above Below

Grammaticality Judgment Score Score Criterion Criterion

Dropped Marker

Agreement

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Screening TestProbe Criterion At/Above BelowScore Score Criterion Criterion

Third Person Singular

Past Tense

Sum ofScreening Probe Scores

Screening Test Score

6057 RF Text_v3_reb1.qxd 3/24/09 1:49 PM

Phonological ProbeMaterials: Stimulus Manual; Examiner’s Manual for complete administration and scoring directions.

Directions: Say, “I am going to show you some pictures and ask you to name some things.” Show the child eachpicture and ask “What is this?” or present the prompt below the item to elicit the response. If the child does not knowthe target word, model the word and ask the child to repeat it.

Recording Responses/Scoring: Record responses verbatim and/or score immediately. Score each item and completethe Phonological Probe Summary according to the directions in Chapter 2 of the Examiner’s Manual.

/s/

1. horse ________________________ 1 0 NR

2. bus ________________________ 1 0 NR

3. dress ________________________ 1 0 NR

4. mouse ________________________ 1 0 NR

5. house ________________________ 1 0 NR

Total Score Final /s/:

/t/

6. foot ________________________ 1 0 NR

7. white ________________________ 1 0 NR(Point to the white paint and ask, “What color is this?”)

8. hat ________________________ 1 0 NR

9. kite ________________________ 1 0 NR

10. boat ________________________ 1 0 NR

Total Score Final /t/:

/z/

11. nose ________________________ 1 0 NR(Point to the nose and ask, “What is this?”)

12. cheese ________________________ 1 0 NR

13. squeeze ________________________ 1 0 NR(Say, “Here is some toothpaste. What do you do to the tube to make the toothpaste come out?”)

14. hose ________________________ 1 0 NR(Point to the hose and ask, “What is this?”)

15. noise ________________________ 1 0 NR(Say, “The boy is banging on the pots. He is making too much _______.”)

Total Score Final /z/:

/d/

16. read ________________________ 1 0 NR(Point to the boy and say, “This boy is going to _______ .”)

17. bed ________________________ 1 0 NR

18. dad ________________________ 1 0 NR(Point as appropriate and say, “Here is the mom and here is the _______ .”)

19. red ________________________ 1 0 NR(Point to the red paint and ask, “What color is this?”)

20. road ________________________ 1 0 NR

Total Score Final /d/:

Phonological

Probe

Summary

Final /s/: � �

Final /t/: � �

Pass / Fail Pass / FailTotal Score (4–5) (0–3) Total Score (4–5) (0–3)

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