ssi 3.pdf resultados

7/23/2019 SSI 3.PDF Resultados

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Identifying Information

Name

Sex M F Grade

Age

Stuttering Severity Instrument 3

TEST RECORD AND FREQUENCY

COMPUTATION FORM

FREQUENCY

Date

School

Examiner

Preschool

Date of Birth

School Age _ Adult _._ Reader _ Nonreader

1. Speaking Task

Task

Score

Frequency Score (use 1 + 2 or 3)

4

6

8

1

12

14

16

18

NONREADERS TABLE

3. Speaking Task

Task

Score

Percentage

1

2

3

5

6 7

8-11

12-21

22

up

Percentage

2 1

3

4

2

5

3-4

5

6

5-76

7

8-12

8

13-208

9

21 up

9

Percentage

1

2

3

5

6 7

8-11

12-21

22

up

Average length of three longest stuttering events

timed to the nearest 1/10th second

Scale

Score

Fleeting

Half-second

1 full second

2 seconds

3 seconds

5 seconds

10 seconds

30 seconds

1 minute

.5 sec or less)

.5- .9 sec)

1.0- 1.9 secs)

( 2.0- 2.9 sees)

( 3.0- 4.9 sees)

( 5.0- 9.9 sees)

(10.0-29.9 sees)

(30.0-59.9 secs)

(60 secs or more)

PHYSICAL CONCOMITANTS

2

4

6

8

1

12

14

16

18

Duration Score (2 - 18)

2 3

2

3

5

2

35

2

3

D

o

o

o

o

=

none

1

=

not noticeable unless looking for it

2

=

barely noticeable to casual observer

3

=

distracting

4

=

very distracting

5

=

severe and painful-looking

Noisy breathing, whistling, sniffing, blowing, clicking sounds

Jaw jerking, tongue protruding, lip pressing, jaw muscles tense

Back, forward, turning away, poor eye contact, constant looking around

Arm and hand movement, hands about face, torso movement, leg movements,

DISTRACTING SOUNDS

FACIAL GRIMACES

HEAD MOVEMENTS

MOVEMENTS OF THE EXTREMITIES

Evaluating Scale



TABLE 2

Percentile and Severity Equivalents of

SSI 3 Total Overall Scores for Preschool Children

= 72

Total Overall

Score

Percentile

everity

8

1 4

Very Mild

9 1

5 11

11 12

12 23ild

13 16

24 4

17 23

41 6oderate

24 26

61 77

27 28

78 88evere

29 31

89 95

32 and up

96 99

Very Severe

TABLE 3

Percentile and Severity Equivalents of SSI 3

Total Overall Scores for School Age Children

=

39

Total Overall

Score

Percentile

Severity

6 8

1 4

ery Mild

9 1

5 11

11 15

12 23

ild

16 2

24 4

21 23

41 6

oderate

24 27

61 77

28 31

78 88

evere

32 35

89 95

36 and up

96 99

Very Severe

TABLE 4

Percentile and Severity Equivalents of

SSI 3 Total Overall Scores for Adults

=

60

Total Overall

Score

Percentile

everity

1 12

1 4

Very Mild

13 17

5 11

18 2

12 23ild

21 24

24 4

25 27

41 6oderate

28 31

61 77

32 34

78 88evere

35 36

89 95

37 46

96 99

ery Severe



CLINIC SPEAKING SAMPLE 1

Syllable Count between 200 and 500 syllables)

Stuttering Events Mark below or use blank paper)

Computation


Syllable Count

Stuttering Events

Computation

HOME SPEAKING SAMPLE 3 optional)

Syllable Count

Stuttering Events

Stuttering Events

Number of Syllables

Stuttering Events

Number of Syllables

x 100

x 100

_____ SS

_____




Syllable Count between 200 and 500 syllables)

Stuttering Events Mark below or use blank paper)

Computation


Syllable Count

Stuttering Events

Computation

HOME SPEAKING SAMPLE 3 optional)

Syllable Count

Stuttering Events

Stuttering Events

Number of Syllables

Stuttering Events

Number of Syllables

x 100

x 100

_____ SS

_____ SS



EXHIBIT C

AUTHORIZATION TO DISCLOSE lNDIVIDUALL Y IDENTIFIABLE

HEALTH lNFORMA TION

I hereby authorize (Covered

Entity) to release the documents described below to:

Recipient Janus Development GrouP. Inc.

Address 112 Staton Road. Greenville. North Carolina 27834

Telephone Number 252-551-9042

DocumentslInformation to Be Released:

Patient name. address. telephone number. email address. date of sale of device

Purpose of Disclosure:

Release of information to manufacturer of anti-stuttering device known as Speech Easy

I understand that the terms of this authorization are governed by the Health

Insurance Portability and Accountability Act of 1996, and its implementing regulations

( HIP AA ). I understand that I have the right to revoke this authorization, at any time

prior to Covered Entity s compliance with the request set forth herein, provided that the

revocation is in writing. I further understand that additional information relating to the

exceptions to the right to revoke and a description of how I may revoke this authorization

as set forth in Covered Entity s Notice of Privacy Practices. I understand that any

revocation must include my name, address, telephone number, date 6fthis authorization

and my signature and that I should send it to:

I understand that Covered Entity may not condition payment, enrollment or

eligibility for benefits on my execution of this authorization except that Covered Entity



1. The authorization is sought for the health plan s eligibility or enrollment

detenninations relating to me or its underwriting or risk rating determinations;

and

2. The authorization is not for a use or disclosure of psychotherapy notes.

I further understand that Covered Entity may condition payment of a claim for specified

benefits on the provision of an authorization if:

1. The disclosure is necessary to determine payment of such claim; and

2. The authorization is not for a use or disclosure of psychotherapy notes.

I understand that the infonnation used or disclosed pursuant to this authorization may be

subject to redisclosure by the Recipient and in that case will no longer be protected by

HIP

This authorization expires upon Covered Entity s release of the information

described above or thirty days after the Date of Authorization as set forth below

whichever comes first.

Printed Name of Individual

Signature of Individual or Personal Representative

Description of Personal Representative s Authority

Date of Authorization