Humble Independent School District



Examiner’s Records for DyslexiaUpdated 2013General Education Process for Identification of Students with DyslexiaStudent ___________________________________________________Process ActivityDocument using Examiner’s Records for DyslexiaDateResults/CommentsStep IData GatheringCumulative Folder Review (Form CFR)Intervention History Review—(attach copies of intervention documents/progress monitoring)Teacher Observation Data (Form TOD)Current Writing and Work SamplesCollect Reading Assessment/Running Record—(can include QRI-3 or 4, Universal Screening Assessment, or alternate benchmark assessment)Classroom Teacher InterventionistBegin to complete Data Review (Form DR)Step IIFormal AssessmentParent Consent Letter/Notification of Rights Parent Information Data (Form PID)Administer Reading Assessments (Benchmark)Comprehensive Test of Phonological Processing - 2 (CTOPP-2)Test of Written Spelling – 5 (TWS-5)Test of Word Reading Efficiency (TOWRE-2)Gray Oral Reading Tests (GORT-5)Step IIIEvaluationDistrict Review (if necessary)504 Committee Review of Data/Determine:Identification of DyslexiaEligibility under Section 504Step IVPlacementDetermine Appropriate Instructional Program and Accommodations/Modifications (if any)Parent Notification/PlacementPermission/Documentation/Distribution of Accommodation Plan (if any)Copy Dyslexia Information and Update (Form IUF)(submit to District Dyslexia Elementary Reading/Language Arts Coordinator, ISC, within 10 days)Place Dyslexia Information and Update Form in student cum folder (Form IUF)Teacher Meeting/General Ed. StaffStep I Data Gathering—Cumulative Folder ReviewStudent Name:Grade:Teacher:Vision passed / failedDate of most current information:Hearingpassed / failedDate of most current information:Were glasses prescribed for schoolwork?yes / noIf yes, does student wear glasses daily?yes / noFamily History of Reading Difficulties yes / noIf yes, specify if suspected or diagnosed:Attentional Issuesyes / noIf yes, specify if suspected or diagnosed:Behavioral Difficultiesyes / noIf yes, explain:Health/Medical History(Please note any relevant medical history)Comments:Language of the home (if other than English):Language of family members (when more than one language is spoken in the home):Mother Father Siblings Others in home English Language Learner’s Educational History Specify Alternative Language Programming/Grade (Two-Way BE, Developmental BE, Transitional BE, ESL Content, ESL Pull-Out, Parent Denial)PK K 1 2 3 4 5 Other: Has this child been identified as a migrant student?yes / noIf yes, explain:List schools/districts student has attended and make note of any lapses. PK Duration of lapse K Duration of lapse 1 Duration of lapse 2 Duration of lapse 3 Duration of lapse 4 Duration of lapse 5 Duration of lapse Other Has student attended school in another country?yes / noIf yes, where and how long:Has the student ever been retained? yes / noExplain:Has this student been formally identified under 504, special education, and/or speech for behavioral or academic concerns?yes / noIf yes, list here:Date services initiated:Discontinued:Current Academic Progress Reportsexcellent / average / poorIf poor, explain:Handwriting Legibilityexcellent / average / poorIntervention(s) (school) Describe and attach plan and dataLevel 1:Level 2:Intervention(s) (private) Describe and attach plan/dataSummer School: List as: A (Attended) DNA (Recommended- did not attend)K ____________1 ____________2 ____________Other:3 ____________4 ____________5 ____________Student’s most current grades Date: As of ________________Reading ________Lang Arts _________Spelling ___________Math __________Science___________Soc Studies _________ State AssessmentGrade 3ReadingScore _____ Pass / FailMathScore _____ Pass / FailGrade 4ReadingScore ____ Pass / FailWritingPass/Fail Score ____Composition Score: ____MathScore _____ Pass / FailGrade 5Reading1st Admin Score _____ Pass / Fail 2nd Admin Score _____ Pass / Fail3rd AdminScore _____ Pass / FailMath1st Admin Score _____ Pass / Fail2nd Admin Score _____ Pass / Fail3rd Admin Score _____ Pass / FailList additional grade level State Assessment results.Provide the most recent years of TELPAS composite scores (if applicable):TELPASScoresYear______Year________Year________Year________ListeningSpeakingReadingWritingAttendance(number of absences)Grade____# of days____Grade____# of days____Grade____# of days____Grade____ # of days____Grade____# of days____Grade____# of days___Grade____# of days_____Grade____# of days____Grade____# of days____Grade____# of days____Other information:Kinder1st2nd3rd4th5thHERSI/HILS EOY Text LevelDBA HistoryGT Assessment(if applicable)Step I: Data Gathering: Teacher Observation Data FormStudent Name Date Teacher/Subject Grade Please check applicable statements AND include examples if possible.The student displays average ability to learn in the absence of print and receives the same classroom instruction that benefits most children; however, the student continues to struggle with some or all of the many facets of reading and spelling. Think about:Does the student exhibit age-appropriate oral language skills, including listening comprehension, vocabulary development, the ability to follow directions, and the ability to tell a story?Does the student exhibit age-appropriate reading comprehension even though his or her word reading skills in isolation are deficient?Is the student’s ability to learn in subjects that are not as heavily reliant on reading, such as science, social studies, and math, grade-appropriate?Is the student’s ability to comprehend information read aloud to him/her age-appropriate?If the student were not asked to read or interact with print, would he/she appear to be age/grade-appropriate?In addition to the above statement, the student may exhibit the following characteristics. These examples may be associated with dyslexia if they are unexpected for the individual’s age, educational level, and cognitive abilities. Based on your classroom observations, please check applicable statements AND include examples if possible. The student:Fails to understand that words come apartHas difficulty learning the letter names and their corresponding soundsHas difficulty decoding single words in isolationHas difficulty spelling phoneticallyReads dysfluently (choppy and labored)Relies on context to recognize a wordHas a history of reading and spelling difficultiesAvoids reading aloudReads most materials slowly; oral reading is labored, not fluentAvoids reading for pleasureMay have an inadequate vocabularyHas difficulty spellingRequires an inordinate amount of time to complete written assignments.Has difficulty copying accurately from near-point. ( i.e. desk work)Has difficulty copying accurately from far-point. (i.e board work)Has difficulty remembering and following directions.Has adequate ability to express self orally but written composition content appears to be below his/her potential.Rate the student’s behavior in relation to other students of the same AGE. For each behavior, mark: 1=Poor, 2=Below Average, 3=Average, 4=Above Average, 5=Superior, N=Not observed12345NWorks cooperatively with othersAppropriate attention and concentrationCompliance with teacher directivesBrings necessary materials to classFidgets, squirms or seems restlessCompletes tasks on timeStays on task, is easily redirectedWhat have you done differently in your classroom to meet this student’s educational/behavioral needs?What were the results of these efforts?Other Academic Concerns:Attach recent student writing samples, current grades, and classwork.Please return to ___________________________________ by _________________Date as completed2 copies sent to parentNotice of Rights included1 copy signed and returnedParent/Guardian Dyslexia Assessment Consent Form (School Copy)Date Sent/Mailed:Student’s Name:Campus:Grade:Student ID:Parents:Address:Home Phone:Work Phone:Dear Parents:We have carefully reviewed your child’s school records and information from teachers. At this time your child continues to exhibit difficulty in learning to read, write, and spell despite the adjustments made to his/her instructional program. The purpose of this letter is to request your permission for the Humble Independent School District to complete an assessment of your child to determine eligibility for services specifically designed for students who exhibit characteristics of dyslexia. Please review the enclosed document entitled “Notice of Parent Rights,” which informs you of your rights under Section 504. If your child is identified as dyslexic, he/she may qualify as a student with disabilities under 504. If you CONSENT to the evaluation, please check the “consent” statement, sign and return one copy of this letter. If you REFUSE consent, please check the “refuse consent” statement, sign, and return one copy of this letter. Keep the other copy of this letter and the Notice of Parents’ Rights for future reference.When the assessment is completed, you will be invited to attend a meeting to discuss the results and, should your child qualify for these services, to assist us in planning an individualized program. If you have any questions, please feel free to contact your child’s teacher. Thank you for your assistance.Sincerely,_________________________________________******************************************************************************************As the parent/legal guardian of the above referenced student, I have received notice of my Section 504 parent rights, and I understand that this is not an offer of a Special Education evaluation.I hereby give CONSENT for the dyslexia assessment to be administered.I hereby REFUSE consent for the dyslexia assessment to be administered.I have received the 504 Pamphlet titled “Notice of Parent and Student Rights under 504, The Rehabilitation Act of 1973.”_________________________________________________Parent/Guardian’s SignatureDateParent/Guardian Dyslexia Assessment Consent Form (Parent Copy)Dear Parents:We have carefully reviewed your child’s school records and information from teachers. At this time your child continues to exhibit difficulty in learning to read, write, and spell despite the adjustments made to his/her instructional program. The purpose of this letter is to request your permission for the Humble Independent School District to complete an assessment of your child to determine eligibility for services specifically designed for students who exhibit characteristics of dyslexia. Please review the enclosed document entitled “Notice of Parent Rights,” which informs you of your rights under Section 504. If your child is identified as dyslexic, he/she may qualify as a student with disabilities under 504. If you CONSENT to the evaluation, please check the “consent” statement, sign and return one copy of this letter. If you REFUSE consent, please check the “refuse consent” statement, sign and return one copy of this letter. Keep the other copy of this letter and the Notice of Parents’ Rights for future reference.When the assessment is completed, you will be invited to attend a meeting to discuss the results and, should your child qualify for these services, to assist us in planning an individualized program. If you have any questions, please feel free to contact your child’s teacher. Thank you for your assistance.Sincerely,_____________________________________******************************************************************************************As the parent/legal guardian of the above referenced student, I have received notice of my Section 504 parent rights, and I understand that this is not an offer of a Special Education evaluation.I hereby give CONSENT for the dyslexia assessment to be administered.I hereby REFUSE consent for the dyslexia assessment to be administered.I have received the 504 Pamphlet titled “Notice of Parent and Student Rights under 504, The Rehabilitation Act of 1973.”_________________________________________________Parent/Guardian’s SignatureDateStep II: Recommendation for Assessment: Parent Information Data FormStudent’s Name: Grade: Male FemaleCampus: DOB: Parent(s): Address: Home Phone: _Work Phone: The information requested will greatly assist the 504 Committee in evaluation of your child. If you have additional information that you want the Committee to consider (and that is not requested here) please feel free to attach additional pages. Please return this form to _______________________________ by _______________.General InformationMother’s Name: Occupation: Father’s Name: Occupation: Do both parents live in the student’s home? Yes NoIf not, with whom does the student live? NameRelationship to childOther children in the home: (attach additional page if necessary)NameAgeRelationship____________________________________________________________________________________________________________Other adults in the home:NameRelationship to Student________________________________________________________________________________________________________________________________________________________The primary language spoken at home is ______________________How long has the child lived in the United States? _______________Have there been any important changes within the family during the last three years? (For example, changes, moves, births, deaths, serious illnesses, separations, divorce)________________________________________________________________________________________________________________________________________________________________________________________________________Describe the student’s behavior at home with peers, siblings, neighbors, parents. (For example, is he/she generally well-behaved, passive or aggressive, social or a loner, affectionate or withdrawn, etc.) ________________________________________________________________________________________________________________________________________________________________________________________________________Do any family members have learning problems? If yes, please explain.________________________________________________________________________________________________________________________________________________________________________________________________________Compared to other children in the family, this child’s development was: (check one) Slower About the same FasterAt what age did your child:Attend to the speaker: ____Babble/imitate sounds: ____Use single words: ____Use 2-3 word phrases: ____Start to name objects: ____Use words to make requests: ____Academic InformationPlease check the appropriate box for the following questions:YesNoDoes your child like to be read to?________Can your child rhyme words?________Can your child follow spoken directions?________Can your child tell a story?________Can your child answer questions about a story he or she has heard?________Do you think your child is having difficulties in school? If yes, please explain:________________________________________________________________________________________________________________________________________________________________________What do you think is causing your child’s difficulties at school?________________________________________________________________________________________________________________________________________________________________________________________________________When did you first notice the difficulties?________________________________________________________________________________________________________________________________________________________________________________________________________What is your child’s attitude towards reading?________________________________________________________________________________________________________________________________________________________________________________________________________Does your child receive any additional help with reading in school or outside school (current or previous)? If so, please describe.________________________________________________________________________________________________________________________________________________________________________________________________________Describe how your child deals with homework assignments (time, attitude, need for help…)________________________________________________________________________________________________________________________________________________________________________________________________________Additional Information: Is there any other information about your student or family that you would like the Section 504 Committee to consider? If so, please provide it here._____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signature of ParentDate_____________________________________________________Signature and Position of Person Assisting (if any)DateStudentDateExaminer’s NameRecord of ScoresComprehensive Test ofPhonological Processing-2 (CTOPP-2)RawScaledDescriptiveSubtestsScoreScoreTermCoreElision (EL)Blending Words (BW)Phoneme Isolation (PI)Memory for Digits (MD)Nonword Repetition (NR)Rapid Digit Naming (RD)Rapid Letter Naming (RL)SupplementalBlending Nonwords (BN)Segmenting Nonwords (SN)CompositesELBW PI SumsCompositeof SSScores PhonologicalAwareness______ ___RDRLRapid Symbolic Naming ___ ____________BN SNAlternate Phonological Awareness______Test of Written Spelling (TWS-5) Descriptive TermRaw ScoreStandard ScoreGray Oral Reading Tests (GORT-5)PretestPost testStoryRateAccuracyFluencyComprehension#ScoreScoreScoreScore1+=2+=3+=4+=5+=6+=7+=8+=9+=10+=11+=12+=13+=14+=TotalScoresRaw%ileScaledDescriptiveTotalRankScoreTermRateAccuracy+FluencyComprehensionSum of Scaled ScoresSum ofOral ReadingOral ReadingDescriptiveScaled Scores%ile RankIndex (ORI)TermTest of Word Reading Efficiency (TOWRE-2)RawScaledDescriptiveSubtestScoreScoreTermSight Word EfficiencyPhonemic DecodingEfficiencySum of Scaled ScoresTotal Word Reading EfficiencyIndex (TWRE)Classification Overview of AssessmentsGuide to Interpreting CTOPP-2 SubtestStandard ScoresGuide to Interpreting CTOPP-2Composite ScoresStandard ScoresDescriptive TermsStandard ScoresDescriptive Terms17-20Very Superior>130Very Superior15-16Superior121-130Superior13-14Above Average111-120Above Average8-12Average90-110Average6-7Below Average80-89Below Average4-5Poor70-79Poor1-3Very Poor<70Very PoorGuide for Interpreting GORT-5Scaled ScoresGuidelines for Interpreting the GORT-5Oral Reading QuotientScaled ScoresDescriptive TermsIndex ScoresDescriptive Terms17-20Very Superior>130Very Superior15-16Superior121-130Superior13-14Above Average111-120Above Average8-12Average90-110Average6-7Below Average80-89Below Average4-5Poor70-79Poor1-3Very Poor<70Very PoorGuide to Interpreting TOWRE-2 Subtest and Total Scaled ScoresGuide to Interpreting Test of Written Spelling (TWS-5) Standard ScoresScaled ScoresDescriptive TermsStandard ScoresDescriptive Terms131-165Very Superior>129Very Superior121-130Superior120-129Superior111-120Above Average110-119Above Average90-110Average90-109Average80-89Below Average80-89Below Average70-79Poor70-79Poor35-69Very Poor<70Very PoorData Review and Recommendation for Dyslexia AssessmentToday’s Date:Student’s Name:Campus:Grade:Student ID:Date of Referral:Examiner/Title:Referral Reason:Teacher ReferralOutside EvaluationParent ReferralTransferARD ReferralBy regulation, the Section 504 Committee is a group of knowledgeable people. List each member attending and check the area of knowledge each provides. Use this chart to document proper attendance. Each type of knowledge must be present for the Committee to be properly constituted under Texas laws for Dyslexia purposes, and Federal law for Section 504 purposes. Note that Committee members can have more than one type of knowledge. For each member, check all boxes of knowledge that apply. (Attach an additional sheet if necessary.)Signature of Committee MemberPosition/TitleThis member has knowledge of…The ChildThe Meaning of the Evaluation DataThe Reading ProcessDyslexia InstructionDistrict, State & Federal GuidelinesThe ChildThe Meaning of the Evaluation DataThe Reading ProcessDyslexia InstructionDistrict, State & Federal GuidelinesThe ChildThe Meaning of the Evaluation DataThe Reading ProcessDyslexia InstructionDistrict, State & Federal GuidelinesThe ChildThe Meaning of the Evaluation DataThe Reading ProcessDyslexia InstructionDistrict, State & Federal GuidelinesThe ChildThe Meaning of the Evaluation DataThe Reading ProcessDyslexia InstructionDistrict, State & Federal GuidelinesData ReviewUse the data gathered in Step I to determine the following:Refer to Forms CFR, TOD, and Intervention Review documentation.YesNoThe student has received conventional (appropriate) reading instruction.The student demonstrates characteristics of dyslexia, demonstrating difficulties in one or more areas of reading and/or the related area of spelling, including phonemic awareness and manipulation, single-word decoding, reading fluency, and learning to spell, that is unexpected for the student’s age/grade.The student has adequate intelligence (an average ability to learn in the absence of print or in other academic areas).The student’s lack of progress was not due to socio-cultural factors such as language differences, irregular attendance, or lack of experiential background.Based on a preponderance of evidence, the Committee shall recommend a formal assessment for Dyslexia.The Committee recommends a formal assessment for dyslexia. If no, return to Level III/Intervention Team to determine next steps.Step I: Data Gathering (Historical Data)Domains to AssessData SourcesScore/LevelCheck OneStrength(Above Average/ Average)Weakness(Below Average/ Poor)Underlying Cognitive Processes (Difficulties in phonological and phonemic awareness are typically seen in students with dyslexia and impact a student’s ability to learn letters and the sounds associated with letters and letter combinations, learn the alphabetic principle, use the sounds of the letters and letter combinations to decode words and to accurately spell.)Phonological ProcessingPhonological Awareness1HERSI- PA InventoryOther:Rapid Symbolic Naming2Other:Academic SkillsLetter Knowledge-names & associated soundsHERSI-Letter IDHERSI-Dictation TaskOther:Reading real words in isolationHERSI-Word TestOther:Decoding non-sense wordsOther:Reading FluencyFluency (Oral Fluency Rubric)Running RecordsDRAOther:AccuracyRunning RecordsDRAOther:Written Spelling3HILS/WTW-Spelling InventoryWriting SamplesHERSI-Writing VocabularyOther:Additional Areas (may be present)Reading ComprehensionDRA/Running RecordsDBAsState AssessmentOther:Written CompositionWriting SamplesDBAsState AssessmentOther:1Note: Because previous effective instruction in phonological/phonemic awareness may remediate phonological awareness skills in isolation, average phonological awareness scores alone do not rule out dyslexia. Ongoing phonological processing deficits can be exhibited in word reading and/or written spelling.2Rapid symbolic naming may or may not be weak, but if deficient, will impact a student’s ability to automatically name letters and read words and to read connected text at an appropriate rate. On-going rapid naming/fluency deficits can also be exhibited on the GORT-5 and TOWRE-2, where tasks are timed. A deficit in reading rate alone would NOT be sufficient to identify dyslexia.3An isolated deficit in spelling would NOT be sufficient to identify dyslexia.After Step I: Data Gathering of Historical Data is complete, refer to the statements on Assessment Overview, page 1, to determine if formal assessment for dyslexia is necessary.Assessment OverviewStudentDate of BirthGradeAgeSchoolDate of AssessmentCompiled byREASON FOR ASSESSMENTTESTS ADMINISTEREDComprehensive Test of Phonological Processing (CTOPP-2)The Comprehensive Test of Phonological Processing (CTOPP-2) assesses three kinds of phonological processing—phonological awareness, phonological memory, and rapid naming:Phonological Awareness – an individual’s awareness of and access to the sound structure of his or her oral language (Mattingly, 1972).Rapid Naming – refers to efficient retrieval of phonological information from long-term permanent memory. The subtests that make up the CTOPP-2 all measure some aspect of phonological processing. The format for each subtest was selected after careful consideration of practical matters (e.g., ease of administration and scoring), and the actual items that make up the subtests were based on results of experimental investigations and statistical research. Subtests include:Elision (EL) – This 34-item subtest measures the extent to which an individual can say a word, then say what is left after dropping out designated sounds.Blending Words (BW) – This 33-item subtest measures an individual’s ability to combine sounds to form words.Rapid Digit Naming (RD) – This 36-item subtest measures the speed with which an individual can name numbers.Rapid Letter Naming (RL) – This 36-item subtest measures the speed with which an individual can name letters. The CTOPP-2 subtests were combined in such a way as to form composites to represent the constructs of phonological awareness, phonological memory, and rapid naming. Test of Written Spelling (TWS-5)The Test of Written Spelling (TWS-5) is a norm-referenced test of spelling. It has two equivalent forms (A and B). The test is administered using a dictated word format. The raw score is the number of items scored correct. The standard score is a transformation of raw scores that establish a common mean score and standard deviation. Gray Oral Reading Tests (GORT-5)The Gray Oral Reading Tests (GORT-5) is a norm-referenced, reliable, and valid test of oral reading rate, accuracy, fluency, and comprehension. Performance on the GORT-5 yields the following scores:Rate – the amount of time taken by a student to read a storyAccuracy – the student’s ability to pronounce each word in the story correctlyFluency – the student’s Rate and Accuracy Scores combinedComprehension – the appropriateness of the student’s responses to questions about the content of each story readOverall Reading Ability – a combination of a student’s Fluency (i.e., Rate and Accuracy) and Comprehension ScoresThe scores of rate, accuracy, fluency, and comprehension are summed and converted to scaled scores. After these scores are recorded, the sum of scaled scores is converted to the overall Oral Reading Quotient (ORQ) – the best measure of a student’s overall oral reading ability. Test of Word Reading Efficiency (TOWRE-2)The Test of Word Reading Efficiency (TOWRE) is a measure of an individual’s ability to pronounce printed words accurately and fluently. The test measures both the ability to sound out words quickly and accurately and the ability to recognize familiar words as whole units or sight words. The TOWRE contains two subtests. The Sight Word Efficiency (SWE) subtest assess the number of real printed words that can be accurately identified within 45 seconds, whereas the Phonemic Decoding Efficiency (PDE) subtest measures the number of pronounceable printed non-words that can be accurately decodes within 45 seconds. Benchmark AssessmentThe Benchmark Assessment System is a standardized, comprehensive assessment that is used to measure a student’s literacy strengths and needs. Students are assessed in the following components:Phonological Awareness TasksBlending Words – Students hear and say the individual sounds in a word and then blend the sounds to say the word. This ability helps students take words apart to solve them.Segmenting Words - Students say a word and then say the individual sounds separately but in sequence. This ability helps students in both spelling and decoding.Letter Recognition – Students say the names of the alphabet by recognizing the shapes of uppercase and lower case letters. High Frequency Words – Students read a list of high-frequency words. This assessment will tell the extent of the student’s knowledge of high-frequency words as well as the particular words they know. Their substitutions will tell what word parts students notice.Writing Picture Names – Students say words slowly and write the sounds they hear. This assessment gives information about whether students can say words slowly, think about the sounds in the words, and record some of them by remembering and writing associated letters. Word Writing – Students write all of the words they can write within a designated time limit. This assessment will give you a rich inventory of what students can control in terms of writing.Reading Record – Students read and talk about a series of benchmark books. This assessment gives valuable information about the student’s reading processing, fluency, and comprehension.Step II: Formal AssessmentDomains to AssessData SourcesScaled/ Standard Score/LevelCheck OneStrength(Above Average/ Average)Weakness(Below Average/ Poor)Underlying Cognitive Processes (Difficulties in phonological and phonemic awareness are typically seen in students with dyslexia and impact a student’s ability to learn letters and the sounds associated with letters and letter combinations, learn the alphabetic principle, use the sounds of the letters and letter combinations to decode words and to accurately spell.)Phonological ProcessingPhonological Awareness1CTOPP-2Elision, Blending Words, & Phoneme IsolationBenchmark PA- Blend/SegmentOther:Rapid Naming2CTOPP-2Rapid Digit & Rapid LetterOther:Academic SkillsLetter Knowledge-names & associated soundsBenchmark-Letter RecognitionBenchmark-Picture NamesOther:Reading real words in isolationTOWRE-2Sight Word EfficiencyBenchmark High Freq WordsOther:Decoding non-sense wordsTOWRE-2Phonemic Decoding EfficiencyOther:Reading FluencyGORT-5Oral Reading QuotientRateGORT-5 Rate Scaled ScoreOther:AccuracyGORT-5 Accuracy Scaled Score Benchmark-Reading RecordOther:FluencyGORT-5 Fluency Scaled Score Benchmark-Reading RecordOther:Written Spelling3TWS-5Test of Written SpellingBenchmark- Word WritingOther:Additional Areas (may be present)Reading ComprehensionGORT-5 Comprehension Scaled ScoreBenchmark- Reading RecordWritten CompositionOther:1Because previous effective instruction in phonological/phonemic awareness may remediate phonological awareness skills in isolation, average phonological awareness scores alone do not rule out dyslexia. Ongoing phonological processing deficits can be exhibited in word reading and/or written spelling.2Difficulties in rapid naming may or may not be weak, but if deficient, will impact a student’s ability to automatically name letters and read words and to read connected text at an appropriate rate. On-going rapid naming/fluency deficits can also be exhibited on the GORT-4 and TOWRE, where tasks are timed. A deficit in reading rate alone would NOT be sufficient to identify dyslexia.3An isolated deficit in spelling would NOT be sufficient to identify dyslexia.After Step I: Data Gathering and Step II: Formal Assessment are complete, refer topage 6 to determine eligibility for dyslexia services.Use the data gathered in Steps I and II to determine the following:YesNoDoes the student exhibit a deficit in phonological/phonemic awareness?If the assessment data does not indicate a deficit in phonological/phonemic awareness, is there a history of the student having difficulty with phonological/phonemic awareness?If there is a previous history, is there data to indicate intervention was provided in this area?Does the student exhibit weaknesses in the ability to read words in isolation with automaticity?Does the student exhibit difficulties with reading accuracy when reading connected text?Does the student exhibit difficulties with reading rate when reading connected text?Does the student exhibit academic weaknesses in spelling?Are the academic weaknesses and the deficits in phonological awareness unexpected for the student in relation to the student’s other cognitive abilities (the ability to learn in the absence of print) and unexpected in relation to the provision of effective classroom instruction?Texas Dyslexia Law EligibilityIn making the determination of dyslexia eligibility, the committee reviewed the evaluation data from Step I and II.Based on the data, mark each area of consideration with “Agree” or “Disagree.”AgreeDisagreeThe student has received conventional (appropriate) reading instruction.The student has experienced as unexpected lack of appropriate progress in the areas of reading and written spelling.The student has adequate intelligence (has average ability to learn in the absence of print or in other academic areas.)Based on the data gathered and reviewed from Steps I and II, the preponderance of evidence shows that the student exhibits characteristics associated with dyslexia; ANDThe student’s lack of progress was not due to socio-cultural factors such as language differences, irregular attendance, or lack of experiential background.If the Committee marked “Agree” in response to each of the preceding five statements, the student is identified as having dyslexia and is eligible for services under the Texas Dyslexia law. If the Committee answered any of the previous five statements with “Disagree,” the student is not eligible under the dyslexia law based on Blue Book criteria, and can only receive dyslexia services through action of a Section 504 Committee or ARD Committee when such services are required to provide the student with a free appropriate public education (FAPE). Note that a student can be identified as having dyslexia by Section 504 Committee or ARD Committee even if Texas Dyslexia Law requirements are not met. This is not, however, a common mittee RecommendationsBased on the evaluation and assessment data from Steps I and/or II, we believe that this student does not meet the eligibility requirements for dyslexia.Based on the evaluation and assessment data from Steps I and II, we believe that this student does meet the eligibility requirements for dyslexia.Based on the evaluation and assessment data from Steps I and/or II, we believe that this student:exhibits severe dyslexia or related disorders; ordisplays additional factors/areas complicating their dyslexiaand should be referred for assessment within the Special Education Program.Return to Intervention Team to determine instructional needs.Individualized, Intensive, Multisensory Reading Instruction (specify)______________________________________________________________________________Referral for Special Education AssessmentDetermine 504 Eligibility(Refer to SSS SpEd/504 Flowchart)Accommodations: Yes NoIf yes, see 504 Accommodation PlanComments: DO NOT DISCARDHumble Independent School DistrictDyslexia Information and Update Form *(Place in student cum folder)Name DOB Student ID Originating Campus Grade Date Examiner & Title Assessment Date Did Not Qualify Qualified (Check all that apply and complete next section.)504Special EducationDirect Services (placed in pull-out Dyslexia Intervention Program)Monitor OnlyPlaced in Alternate Accelerated Intervention (Please describe.)Parent Refused ServicesOtherYes:?First Lesson Date ?End of Year or Transition UpdateDate Lesson Completed Date Lesson Completed Date Lesson Completed ?Exit Date Lesson Completed Comments:* Copy submitted to District Dyslexia/Elementary Reading/Language Arts Coordinator, ISC within 10 days of Placement Meeting. In addition, update at end of the year or program exit. ................
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