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CLQT Record Form

An Assessment tool for Cognitive Linguistic

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Briggs Emmanuel Poblete
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23K views16 pages

CLQT Record Form

An Assessment tool for Cognitive Linguistic

Uploaded by

Briggs Emmanuel Poblete
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
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Cent ee eae Cognitive Linguistic Quick Test Be : ; cco, ‘Name: Oe ID Number:__ Dae, est aaa — Date of Phone Number: Years of Bducation:_ | Birth L Age Presend/Former Occupation: Marital Stats: Gender: Male FemaleQ Handedness: Left) Right O ee Nave Languages Lenton WNL* Mild Moderate Severe Languages Spoken: Memory WNL Mild Moderate Severe Primary Diagnosis: Executive Functions WNL Mild Moderate Severe Language WNL Mild Moderate Severe: Den Ova Visuospatal kills WNL Mild Moderate Severe Hemiparesis: Yes. NoO Side of Hemiparesis: Left) Right Q. Moderate "Within normal limits Shen) —__ ae Other Medical Probler Describe the presence of pertveraton, rexpones delay a correction, “set” pion cecperoon, red prong response, uninlligibly, or ober observations. See Chapler 3and 4 fy te Severity of Hemiparesis: Mild Q. Moderate Q Severe O (Current Medication(s, Examiners Name: Referral Source: ‘Contact Person: Phone Number: __ Relationship to Examinee THE @ PSYCHOLOGICAL CORPORATION® ‘Harcourt Assessment Company ISBN 015-4328-04-9 peg 0 2001 y The Fy Corin, ‘fzcaa tenet Cota Slap heed Prmtin tbe United tae Ane ole 119221 2ABCDE — zis To reorder CLOT Record Forms, call: 1-800-872-1726 General Administration Directions 1. Administer the tasks in the order in which they appear on the Record Form. 2. Refer to the Examiner's Manual for detailed administration and scoring directions and examples. 3. Soy directions printed in dark blue to the examinee. Use a riormal conversational rate and slress patiern, @: Facts N/A Provided for individual items Directions: Administer each item in the order listed. Do not allow the examinee to use reminders (e.g., calendar, address book). Repeat the item if requested or if here is no response after 10 seconds Soy, “Lwant to cheek some facts.” Probes: Probes are listed alfer items 1, 2, ond 4. Administer once if the exominge gives an incomplete response cr does not understond the item Recording and Scoring: Write the exominee’s response to each item and circle the score. Circle one or more of the descriptions if applicable 1."When were you bom?” | Month... 1 | 0 | 5p] sc|pr| p | UN | pr (For incomplete responses, probe for mon doy, or year) 1 | 0 | 5D| sc | pR| Pp | UN | nr 1 | 0 | 50] sc | pr| p_|UN| np 2."Where were you bom?"* | city Forceps repens, pobe 1 | 0 | 5D| sc | PR) P| UN. NR for the city oF stote [country} ) State (Country)... ‘3."What is your age now?” | Age..... fr 0 | 5D | SC | PR P | UN) AR 1." What is ‘Number Ee se reeks: ae 1 | 0 |5D/sc| pr p|UN| xR Fr ncomglee reeponuny, probe forthe soot, ci ote | City non ~-| 1 | 0 | 5D | sc | PR| P | YN | NR ‘No ZIP code is needed.) State = ~~-| 110 | sp | sc | pr| P| UN | NR ® The examinee must state both the city and state (country) 10 ae tecae | pon Ifyou dor know he examinees el ond sate (county) of birth, score | point for @ plausible response. | ian’s Note Piso bl memory ond longuoge abiliies. Examinees with aphasia may respond the items due to languoge problems. Se fe nomeryareby Yr oor ed nan is No whe enc ‘dmonsrot beta vost il (ese or poe of its eurent ‘oddress) a pater sen expecially in individuals wih dementia ond closed injury. Delayed and/or selcoreced responses may indicate milder memory problems. — You may repeat he rections I time. Directions: Open the Response Booklet so that pages 1 and 2 are facing the examinee. Present the demonstration iim on page |. Say, “Look at this symbol. (?oini to the forget symbol on page 1.) This symbol appears several times on this page. (Point to page 2 of the Response Booklet) Point to one. {Wait for the examinee's response. Correct an incorrect response by pointing to a symbol near the center of the page.) I'm going to cross out the symbol.” Go back to page 1 end place an X on the symbol onthe Demonstration lem tat matches he lrget sym Say, “Now, I want you to cross out every example of this symbol (pin! fo Ihe ‘orge! symbol en page 1) on this page [point o page 2). Do you have any questions? (Repeat the insiructions i necessary You have 2 minutes, [Give the examinee pen} Start now." Leave page | in view and begin timing, : IF the examinee abandons the task before completion, encourage him or her to continue (until the 2 minuie ceadl ne) by saying something ke, “Keep going: you have time left,” or “Are you finished? Go back and check your work.” Do not provide any information regarding the accuracy of he responses and do not prompt for missed targets. Recording and Scoring: Use the Symbel Cancllaon Scoring Traspareny io determin correctly and incorrectly cancelled symbols by quadrant. Record the numbers in the appropriate boxes below. Upper left Upper Right) | Upper left Upper Right | lower Left Lower Right | Ifthe difference is ‘onagative number, score as 0. [77] Number of | Sel-Corrected Responses cea mete Note kof offers infos cing the integrity of Cancellation is a nonlinguistic task of visual attention and perception. It also offers information re i yt Ro eener end tome od cut Sito noht yal taki Glaeets otttinesd sear seen eee eee from leh to ight, down ond up, or scannieg unsysomatialiy? Neste if examninaes fllad lo coreal symbols h one, or Sore of telour queens, Ero of ison (covet sls not cencaled and conmasion (resect syns concn) my ba secondary to: 1. generalized inattention, 2. visual discrimination problems, 3. partial or full hemianopsio, 4. visual neglect, or 5. inattention to one side or quadrant of space. Observe whether there are similar visual field deficits on Clock Drawing, Symbol Trails, and Mazes tasks. See Chapter 3 in the Examiner's Manual for more information. I romp! fora “common name” ‘0 singleword response. Directions: Say, “Now, I want you to name some pictures.” Turn to page | of the Stimulus Manual and present ihe first picture ond soy, “What is this?” Then present the remaining piciures (pages 2-10). You may say, “What is this?” or “...and this one?” as you present each picture. Prompts: If the examinee gives a seldom-used word (e.g., “four-in-hand"/tie], ask for the common name. If the examinee gives an elaborated response [e.g., banana with peeling), oxk fora single word. Do not provide additional prompls or probes: Recording and Scoring: Record incorrect responses verbatim. Circle 1 point for.a correct response, an acceptable variation of a correct response, o dialectal variation, or a commonly accepted synonym for the stimulus. Circle Vf point if he examinee produces atleast haf ofthe thonemes or sylables correcly, live no credit for responses that have less than half of the phonemes or syllables correct. Circle one or more of the descriptions if applicable. = 1) 1/0 | 5D/ sc) P| UN NR 2. chair 1) } | 0 5D} SC) P| UN| NR en : itiie “sD | sc | P| UN. NR 4. hammer 1 | 3 | 0 | sp] sc| P| UN| NR 5. (neek)tie 1] 4 [0 | 5D] sc} P| UN| NR 6, train 1 | } | 0 | 5D} Sc) P| UN| AR 7. chicken/hen/rooster 13 | 0 | 5D) sc PUN NR 8. banana 10 | 5D) SCP OUN NR 9. shirt 1 | 3 | 0 5D} SC) P| UN| NR 10. zipper 3 | 0 | 5D] sc| P | UN| NR ae cat ate ician’s Note per cla, Deficits in confrontation naming are a key s) asia that can result from vorious forms of brain damage {e.g., stroke, injury, damento, tors loan Boe erage ayer Nol ied Sloe permranon fepeal 56) of all or part ofa previous word. Alhough no points ate deducted, an elaborated response may be symplomatic of yetbosty or incbity¥ it information. Ak the examinee fo give a ingle word response. Use of seldom-sed words ay bo symptom of word Roding problems. Request “common name.” The ypes 5 erors examinees make con guide Neaiment of wordcetival problems, See Chopler3 {he Examiner's Manual fr various types of naming erors thot may provide diferentiel diagnostic information cc k Drawing Yeu may repeat directions | time. Directions: Place page 3 of the Response Booklet and a pen in front of the examinee. Soy, “I want you to draw a clock on this page. (Po 1 Ihe

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