Dyslexia Checklist - North East Independent School District
3314700-342900Dyslexia ChecklistName: __________________________Date of Assessment: ________________ Grade: ______ Teacher: _____________For Students 10 years and older ChecklistForm:Date504 Referral MeetingParent Response FormTeacher Checklist Vision/HearingWork SamplesTest Given:DateListening Comprehension CTOPP2 (core only)WRMT-III (test 4,5,6,8)Gort-5Alphabet (written/oral)Days of Week (written/oral)Months of Year (written/oral)Spelling Inventory (Words Their Way) (primary or elem.)Optional: Cognitive (when listening is low due to attention difficulty)Date of 504/ARD meeting: ___________Qualified: YesNoSpecial Ed.YesNo Forms:Dyslexia Notification for Parents (Middle School only): _____ Intervention Class:(Elementary) Spire:YesNo(Gr 6-8) Megawords:YesNoAccommodations YesNoNotes/Comments:00Dyslexia ChecklistName: __________________________Date of Assessment: ________________ Grade: ______ Teacher: _____________For Students 10 years and older ChecklistForm:Date504 Referral MeetingParent Response FormTeacher Checklist Vision/HearingWork SamplesTest Given:DateListening Comprehension CTOPP2 (core only)WRMT-III (test 4,5,6,8)Gort-5Alphabet (written/oral)Days of Week (written/oral)Months of Year (written/oral)Spelling Inventory (Words Their Way) (primary or elem.)Optional: Cognitive (when listening is low due to attention difficulty)Date of 504/ARD meeting: ___________Qualified: YesNoSpecial Ed.YesNo Forms:Dyslexia Notification for Parents (Middle School only): _____ Intervention Class:(Elementary) Spire:YesNo(Gr 6-8) Megawords:YesNoAccommodations YesNoNotes/Comments:-228600-342900Dyslexia ChecklistName: __________________________Date of Assessment: ________________ Grade: ______ Teacher: _____________For Students 10 years and older ChecklistForm:Date504 Referral MeetingParent Response Form Teacher Checklist Vision/HearingWork SamplesTest Given:DateListening Comprehension CTOPP2 (core only)WRMT-III (test 4,5,6,8)Gort-5Alphabet (written/oral)Days of Week (written/oral)Months of Year (written/oral) Spelling Inventory(Words Their Way) (primary or elem.)Optional: Cognitive (when listening is low due to attention difficulty)Date of 504/ARD meeting: ___________Qualified: YesNoSpecial Ed.YesNo Forms:Dyslexia Notification for Parents (Middle School only): _____ Intervention Class:(Elementary) Spire:YesNo(Gr 6-8) Megawords:YesNoAccommodations YesNoNotes/Comments:00Dyslexia ChecklistName: __________________________Date of Assessment: ________________ Grade: ______ Teacher: _____________For Students 10 years and older ChecklistForm:Date504 Referral MeetingParent Response Form Teacher Checklist Vision/HearingWork SamplesTest Given:DateListening Comprehension CTOPP2 (core only)WRMT-III (test 4,5,6,8)Gort-5Alphabet (written/oral)Days of Week (written/oral)Months of Year (written/oral) Spelling Inventory(Words Their Way) (primary or elem.)Optional: Cognitive (when listening is low due to attention difficulty)Date of 504/ARD meeting: ___________Qualified: YesNoSpecial Ed.YesNo Forms:Dyslexia Notification for Parents (Middle School only): _____ Intervention Class:(Elementary) Spire:YesNo(Gr 6-8) Megawords:YesNoAccommodations YesNoNotes/Comments: ................
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