Dyslexia Screening Booklet ‘The Dyslexia Screening Booklet is a referral document that needs fo be completed by both the teacher and parents. I is designed for teachers and parents to provide Educational Psychologists with key information to assist thems in identifying primary ‘school children who exhibit specific literacy difficulties or dyslexia. CONTENTS OF BOOKLET Background Information p2 Teacher's Checklist pas Parent's Checklis pes USING THE BOOKLET Complete all sections Ensure parents are given the Parent's Checklist o complete “Attach recent samples of pupil's school work Submit the entire booklet, together with samples of work to the school Educational Psychologist (via LSC) for follow-up OVERALL ASSESSMENT PROCESS ‘Teacher suspects child has major difficulty with teracy tasks + MOE Dyslexia Serening Booklet is completed a Completed Dyslexia Sereenin Boole, Samples of Work and Copies of Other Relevant ‘Documents are Given To School EP/ LSC + EP Cont Psychological Assessment ¥ EP Meets Parenss 1 EP Meets Teachers (where necessary) v EP Writes Psychological Report or Assessment Summary 1F pupil meets the entrance extra is shown tobe pupil with sex), EP Recommends Chil #9 DAS Dyslexia Serening Boolet: 1BACKGROUND INFORMATION Tobe completed by school personnal Name of Chit Coe eee Bc: Gender: * Male / Female Race: Schoo! Class: ‘Session: *AM/ PM Home Address: Parent's Name Parent's Contact Nos: (Home) (or (Hp) Father's Occupation: ‘Mother's Occupation: Kindergarten name: No of years: (Outside Agency / External Professional Involvement ‘School Performance Record: English Mother Tongue SAL SAZ SAL ‘SAZ Pi PZ P3 Pa PS Pe Parental Consent Obtained : YES ‘NO Person making Referral Date: Relation to Chil Dyslexia Soreening Booklets 2TEACHER'S CHECKLIST Please indicate to your best knowledge if the child shows significant difficulties in the following areas. Where necessary, teacher should carry out observations in order (0 ‘provide more accurate information. Please be reminded that samples of the child's work should be included. YES [NO READING T. Reads very slowly 2. Reads hesitantly 3. Constantly Toses place, e.g, misses out whole chunks of passage or repeating paragraphs 4. Difficulty tracking words along a line of print 5. Frequently skips or re-read a line of words 6. Difficulty recognising familiar words, eg, there, his, with, want 7. Confuses similar looking words, e.g. on/no, was/saw 8. Misreads initial consonants, e.g. might for night 9, Guesses wildly at words 10. Substitutes words of similar meaning, e.g. jungle for forest TT. Distegards punctuation, ¢g. reads without appropriate pauses 12, Misreads words by changing the position of leters within the sword, e.g tired for tried; bread for beard. 13. Misreads syllables, e.g. hopsital for hospital 14. Difficulty comprehending a passage even if correctly read PHONOLOGY 1. Difficulty identifying words with the same beginning sound, € fat and fox; tin and top 2. Difficulty identifying rhyming words, e.g. Jil and hill, mop and top ‘SPELLING! WRITING T. Poor standard of written work, Le. written work is usually full of spelling and grammatical errors 2 Standard of written work not equal to ability in oral language, Fe child speaks better than he/she writes Dyslexia Screening Booklet: 3YES [NO 3. Messy and poorly organised work, often full of corrections and erasure marks 4. Poorly organized work, characterised by irregular spacing between words 5. Poor penmanship, e.g. letters written in different sizes, letters hardly written on the line Bizarre spelling, e.g. ‘pokegt for ‘pocket’; Fedury” for “February” Confusion of letters that look similar, e.g. h/n/r, miniw Mirror-writing of letters and numbers, eg, b/d, pig, 67 Foreshortening of words, eg, ‘rember’ for ‘remember’, “sudly” for ‘suddenly’ 10. Wrong order of letters in words, e.g. ‘hlep' for ‘help’, ‘brid? for “bird” TT. Indiseriminate use of capitals, eg, John haS A peN 12, Difficulty writing the alphabet in sequence 13. Difficulty copying accurately from the whiteboard 14, Difficulty writing letters even when they are dictated in name MOTOR SKILLS 1. Appears clumsy 2. Difficulty catching or throwing a ball 3. Difficulty hopping or skipping ‘SPEECH, CONCEPTS AND MEMORY 1. Difficulty finding the right words for things (e.g. persistent word searching) Persistently jumbles phrases Difficulty distinguishing left and right Difficulty telling time 5. Difficulty remembering days of the week 6. Difficulty remembering own birthday, telephone number, address 7. Difficulty with the concepts of yesterday and tomorrow 8. Difficulty following a sequence of verbal instructions Dyslexia Sereening BooklerBEHAVIOUR T. Shows difficulty displaying attentive behaviour (eg. looking at teacher, listening to teacher) when teacher is instructin ‘Shows difficulty completing tasks on time 3. Easily distracted by sounds Easily distracted by actions of others Easily distracted by bright lights Easily frustrated (e.g. becomes angry quickly) Tacks interestmotivation in academic tasks 5 6 7, Easily reduoed to Wars % 5, 9. Lacks continuity of effort and perseverance TO. Does not stay in his seat TT. Does not bring materials needed for lessons 12, interrupts the teacher during Tessons 12, Constantly seeks attention, approval and/or praise T3. Constantly fidgets and is restless 4. Passive in class, rarely inating conversation or responding in class, unless called upon 15. Withdrawn in class, deliberately avoiding interaction with teacher/peers 17. Fights/quarrels with peers PHYSIOLOGY T. Does the child have problems with eyesight? Does the child have problems with hearing? Dyslesia Serening Booklet: §Chitd’s strengths = Child's main difficulties in school: ‘Support provided for child in class /school: Language most frequently used by the child with his peers in school: Additional Information - ‘Teacher Dat ‘Teacher's teaching subjects : Daslona Sereening Bookie 6PARENT'S CHECKLIST “Deak is prion For paves NAME OF CHILD: Date of Birth : Class Dear parent(s), This is to assist usin gaining a better understanding of your child's learning difieltes. Please indicate to your best knowledge if your child shows significant difficulties in the following areas. li may be necessary 10 carry out some observations in order 10 provide ‘more accurate responses, YES [NO READING T. Reads slowly 2. Reads hesitantly ‘Constantly loses place, ¢g, misses out whole chunks of passage oF repeating paragraphs Difficulty tacking words along a line of print ‘Frequently skips or re-zeads a line of words Difficulty recognising familiar words ‘Confuses similar ooking words, eg. on/ho, wassaw “Misreads inital consonants, eg: might for night ‘Guesses wildly at words 10, Substitutes words of similar meaning, e.g. jungle For forest TI. Disregards punctuation, e.g. reads without appropriate pauses 12, Misreads words by changing the position of letters within the word, e.g. tired for tied: bread for beard 13. Misteads syllables, e.g, hopsital for hospital 14. Difhiculty comprehending a passage even if correctly read PHONOLOGY 1. Difficulty identifying words with the same beginning sound, eg fat and fox: tin and top 2. Difficulty identifying rhyming words, eg. Jl and hill, mop and top Screening Boole: 7‘SPELLING/ WRITING T. Poor standard of written work, ie. written work is usually fall of spelling and grammatical errors 3. Standard of written work not equal to ability in oral language, 1. child speaks better than he/she writes 3. Messy work, often full of corrections and erasure marks 4. Poorly organized work, characterized by inegular spacing between words . Poor penmanship, Ieters written in different sizes, leters hardly written on the line Bizarre spelling, e.g. ‘pokegi for ‘pocket ‘Fedury” for ‘February Mirrorwriting of letters and numbers, eg. B, pla, 67 6 7 Confusion of leters that look similar, eg. Wave, minw a 9. Foreshortening of words, eg. rember” for ‘remember, “sudly” for “suddenly” TO. Wrong onder of eters in words, eg, “hlep’ for ‘help’, “bird” TI, Indiseriminate use of capitals, eg. John haS A peN Tor 12, Difficulty writing the alphabet in sequence 13. Difficulty writing letters even when they are dictated in name ‘MOTOR SKILLS T. Appears clumsy 2. Difficulty catching or throwing a ball 3._ Difficulty hopping or skipping 4. Difficulty fastening shoclaces ‘SPEECH, CONCEPTS AND MEMORY T._ Difficulty finding the right words for things (e.g. persistent word searching) 2. Persistently jumbles phrases 3. Difficulty distinguishing left and ight Difficulty telling time Difficulty remembering days of the week Difficulty remembering own birthday, telephone number, address Difficulty with the concepts of yesterday and tomorrow yslenia Sereening Boollet:‘Difficulty following a sequence of verbal instructions BEHAVIOUR T._ Shows difficulty displaying attentive behaviour (e.g. looking at andlor listening to the person speaking) ‘Shows difficulty completing tasks on time Easily distracted Easily frustrated (eg becomes angry easily) Easily reduced to tears TLacks motivation/interest in academic tasks Tacks continuity of effort and perseverance Constantly seeks attention, approval and/or praise ‘9, Passive, rarely initiating conversation at home 10. Withdrawn, deliberately avoiding interaction with family members PHYSIOLOGY T, Delayed speech milestones, Le. developing speech later than the age of 2 2, Delayed motor milestones, Le. starting to walk later than the age of 2% years Late in deciding which hand to use rs “Any eyesight problems? “Any hearing problems? “Any family story of reading difficulties? Dyslexia Soreening Booklet: 9Child's strengahs: Chitd’s main difficulties: Medical history (e.g. accidents, illness, hospitalisation): Outside agency or professional involvement (e psychiatrist, occupational therapist, speech & language therapist, psychologist, learning centre/tuition, ete): ? tails: Most frequently spoken language(s) at home - Additional Information — Name & Signature of Parent Date: Dyalera Seong Bootle: 10