WEST ATHENS ELEMENTARY SCHOOL Speech and Language
Prevention and Screening Request
Student's Name *
Your answer
Teacher's Name *
Your answer
Grade *
Your answer
Date Of Birth *
MM
/
DD
/
YYYY
Room Number *
Your answer
Language Classification *
ELD Level
Your answer
How long has student been exposed to English? *
Your answer
How long has student been at current ELD Level?
Your answer
Has student met ELD goals?
Your answer
Articulation Difficulties
Stuttering Difficulties
Language Difficulties
Voice Difficulties
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