Examiner’s Records for Dyslexia
Examiner’s Records for Dyslexia
Humble ISD
Humble Independent School District
Process Checklist for
(Student)
General Education Process for Identification of Students with Dyslexia
| |Process Activity |Date |Results/Comments |
|Part I |Data Review | | |
|Data Gathering|Cumulative Folder | | |
|(May be a | | | |
|two-step | | | |
|process) | | | |
| |Core Team File | | |
| |Teacher Observation Data Form | | |
| |Identification Profile | | |
| |Writing Sample | | |
| |Reading Inventory (QRI-3 or 4) | | |
| |Committee Recommendation | | |
| | | | |
|Part II |Parent Permission Documentation | | |
|Recommendation| | | |
|for Assessment| | | |
| |Parent Information Data Form | | |
| |Comprehensive Test of Phonological Processing (CTOPP) | | |
| |Test of Written Spelling – 4 (TWS-4) | | |
| |Test of Word Reading Efficiency (TOWRE) | | |
| |Gray Oral Reading Tests (GORT-4) | | |
| | | | |
|Part III |District Review (if necessary) | | |
|Evaluation | | | |
| |504 Committee/Core Team/Special Service Team | | |
| |Recommendation/Documentation | | |
| |Characteristic Profile of Dyslexia | | |
| | | | |
|Part IV |Determine Classroom Accommodations/ Modifications and TAKS Bundle | | |
|Placement | | | |
| |Parent Notification/Placement | | |
| |Permission/Documentation/Distribution of Accommodation Plan (if | | |
| |any) | | |
| |Copy Dyslexia Information and Update Form (submit to District | | |
| |Dyslexia Elementary Reading/Language Arts Coordinator, ISC, within | | |
| |10 days) | | |
| |Place Dyslexia Information and Update Form in student cum folder | | |
| |Teacher Meeting/General Ed. Staff | | |
Humble ISD
Identification Profile for Dyslexia
Part I Data Gathering: Data Review
Student Name School
Student ID# Grade Date of Birth
Years Retained Male/Female
Date of Screening Completed by
Directions: Consult other staff members such as teachers, counselor, nurse, etc., and available data. Check statements that are applicable. Please attach Teacher Observation Data Forms, Writing Sample(s), and Reading Inventory results. If all of these items are supportive, then proceed to Part II.
_______ Student is currently receiving accelerated instruction (Literacy Support/Basic Skills, tutoring, ESL class, retention, summer school, private tutor, etc.) in addition to regular Language Arts or English class.
_______ Student appears to have adequate mental ability.
_______ Student has received near and far point screening of vision and all recommendations for treatment have been followed.
_______ Student has received additional screening for hearing, and all recommendations for treatment have been followed.
_______ Student is proficient in the English language. (Refer to LPAC data.) If not, consult with bilingual child study team to determine if further screening is needed.
_______ Student has attended school on a regular basis. If this item is not checked, complete the support data below.
Days present _______
Days absent _______
Number of schools attended _______
_______ Student is reading one or more years below grade level.
Classroom reading level is _______
Reading Inventory Level _______ Instrument used _______
Reading/LA Grades (Report Card) _______
TAKS _______
Humble ISD
Part I Data Gathering: Teacher Observation Data Form
Student Name ___________________________________ Date ______________________
Teacher/Subject _____________________________________________ Grade _________
Directions: mark each characteristic: Y = Yes N = No ? = Don’t Know
| |Y |N |? |Characteristics |
|1. | | | |Student fails to learn to read, write, or spell with typical approaches used in classroom. |
|2. | | | |Student requires an inordinate amount of time to complete reading tasks due to text level. |
|3. | | | |The student’s difficulty in reading, writing and spelling is unexpected for his ability, age, and grade |
| | | | |level. |
|4. | | | |Student may lose comprehension in the struggle with the mechanics of reading. |
|5. | | | |Student may have difficulty reading single words in isolation. |
|6. | | | |Student may have difficulty hearing sounds in words. |
|7. | | | |Student may have inaccurate and labored oral reading. |
|8. | | | |Student may have difficulty learning the names of letters and their associated sounds. |
|9. | | | |Students may have difficulty with learning and reproducing the alphabet in correct sequence (in either oral |
| | | | |or written form). |
|10. | | | |Student has extreme difficulty with learning to spell. |
|11. | | | |Student may learn to spell a list of words sufficiently well to pass weekly test but does not retain. |
|12. | | | |Student may have letter reversals; rotations and/or transpositions; add or omit whole syllables in reading, |
| | | | |writing, and/or spelling. |
|13. | | | |Student may have adequate ability to express self orally but written composition content appears to be below |
| | | | |his or her potential. |
|14. | | | |Student may have unusual difficulty with handwriting and motor skills. |
|15. | | | |Student requires an inordinate amount of time to complete written assignments. |
|16. | | | |Student has difficulty copying accurately from near-point, i.e., desk work. |
|17. | | | |Student has difficulty copying accurately from far-point, i.e., boardwork. |
|18. | | | |Student has difficulty remembering and following directions. |
|Totals | | | | |
|Accommodations and modifications provided by classroom teachers: |
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Please return to Dyslexia Instructional Support by _____________________.
HUMBLE INDEPENDENT SCHOOL DISTRICT
PARENT/GUARDIAN CONSENT FOR DYSLEXIA ASSESSMENT
Dear Parents:
Your child, _____________________, is currently placed in the ______________________
program in grade______. __________________ 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. 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.
Attached is a pamphlet for your information titled “Notice of Parent and Student Rights Under 504, the Rehabilitation Act of 1973.” If your child is identified as having characteristics of dyslexia, he/she may qualify as a student with disabilities under 504.
Please sign and return this letter indicating that permission for dyslexia assessment is granted and you have received your copy of the 504 pamphlet. If you have any questions, please feel free to contact your child’s teacher. Thank you for your assistance.
Sincerely,
_____________________________________
**************************************************************************
Parent/Guardian Consent
( I grant my permission for the ( I do not grant permission for the
dyslexia assessment to be administered. 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 Signature
_________________________________
Student’s Name
_________________________________
Date
Humble ISD
Part II Recommendation for Assessment: Parent Information Data Form
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|Student’s Name Grade Age Date of Birth |
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|Person Being Interviewed/Surveyed Relationship Interviewer, if applicable Date |
|1. List three positive strengths of your child. |
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|2. How did your child’s early language development compare to that of other children? |
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|3. At what age did your child: |
|Attend to the speaker Use two-three word phrases |
|Babble/imitate sounds Start to name objects |
|Use single words Use words to make requests |
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|4. Describe your child’s early reading experiences at home and school. |
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|5. Does your child like to be read to? Yes No |
|Can your child rhyme words? Yes No |
|Can your child follow spoken directions? Yes No |
|Can your child tell a story? Yes No |
|Can your child answer questions about a |
|story he or she has heard? Yes No |
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|6 What is your child’s attitude toward reading? |
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Page 1 of 2
Part II Recommendation for Assessment: Parent Information Data Form
|7. Does your child receive any additional help with reading in school or outside school? |
|If so, please describe. |
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|8. Describe how your child deals with homework assignments (time, attitude, need for help…). |
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|9. Describe any reading or learning problems experienced by family members. |
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|10. Describe any specific illnesses, accidents, and/or allergies. |
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|11. Describe any difficulty your child has with balance, following directions, etc. |
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|12. Is there any additional information about your child that you would like to provide? |
|Please explain. |
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Page 2 of 2
Student Date Examiner’s Name
Humble Independent School District
Summative Report for Dyslexia Assessment
Record of Scores
Comprehensive Test of
Phonological Processing (CTOPP)
Raw Std.
Subtests Score Score
Core
I. Ellision (EL)
II. Blending Words (BW)
III. Memory for Digits (MD)
IV. Rapid Digit Naming (RD)
V. Nonword Repetition (NR)
VI. Rapid Letter Naming (RL)
Supplemental
VII. Rapid Color Naming (RC)
VIII. Phoneme Reversal (PR)
IX. Rapid Object Naming (RO)
X. Blending Nonwords (BN)
XI. Segmenting Words (SW)
XII. Segmenting Nonwords (SN)
Composites
EL BW MD RD NR RL Sums Composite
of SS Scores
Phonological
Awareness ___ ___
Phonological
Memory ___ ___
Rapid Naming ___ ___
RC RO BN SN
Alternate Phonological
Awareness ___ ___
Alternate Rapid Naming ___ ___
Test of Written Spelling (TWS-4)
Raw Score
Standard Score
Gray Oral Reading Tests (GORT-4)
Pretest Post test
Story Rate Accuracy Fluency Comprehension
# Score Score Score Score
1 ____ + ____ = ____ ____
2 ____ + ____ = ____ ____
3 ____ + ____ = ____ ____
4 ____ + ____ = ____ ____
5 ____ + ____ = ____ ____
6 ____ + ____ = ____ ____
7 ____ + ____ = ____ ____
8 ____ + ____ = ____ ____
9 ____ + ____ = ____ ____
10 ____ + ____ = ____ ____
11 ____ + ____ = ____ ____
12 ____ + ____ = ____ ____
13 ____ + ____ = ____ ____
14 ____ + ____ = ____ ____
Total
Scores
Standard
Scores
Sum of Fluency and Comprehension Standard Scores
Oral Reading Quotient (ORQ)
Test of Word Reading Efficiency (TOWRE)
Raw Std.
Subtest Score Score
I. Sight Word Efficiency
II. Phonemic Decoding
Efficiency
Sum of Standard Scores
Humble Independent School District
Summative Report for Dyslexia Assessment
Classification Overview of Assessments
|Guide to Interpreting CTOPP Subtest Standard Scores | |Guide to Interpreting CTOPP Composite Scores |
| | | | | |
|Standard Scores |Classification | |Standard Scores |Classification |
|17-20 |Very Superior | |131-165 |Very Superior |
|15-16 |Superior | |121-130 |Superior |
|13-14 |Above Average | |111-120 |Above Average |
|8-12 |Average | |90-110 |Average |
|6-7 |Below Average | |80-89 |Below Average |
|4-5 |Poor | |70-79 |Poor |
|1-3 |Very Poor | |35-69 |Very Poor |
|Guide for Interpreting GORT-4 Standard Scores | |Guidelines for Interpreting the GORT-4 |
| | |Oral Reading Quotient |
| | | | | |
|Standard Scores |Classification | |Standard Scores |Classification |
|17-20 |Very Superior | |>130 |Very Superior |
|15-16 |Superior | |121-130 |Superior |
|13-14 |Above Average | |111-120 |Above Average |
|8-12 |Average | |90-110 |Average |
|6-7 |Below Average | |80-89 |Below Average |
|4-5 |Poor | |70-79 |Poor |
|1-3 |Very Poor | |130 |Very Superior |
|121-130 |Superior | |121-130 |Superior |
|111-120 |Above Average | |111-120 |Above Average |
|90-110 |Average | |90-110 |Average |
|80-89 |Below Average | |80-89 |Below Average |
|70-79 |Poor | |70-79 |Poor |
|35-69 |Very Poor | | ................
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