|Bulletin 1903 Screening & Intervention for School Success
DYSLEXIA SCREENING INDICATORS’ REFERRING TEACHER/PARENT CHECKLIST
Student: __________________________ School: _____________________
Teacher: _______________________ Date of Assessment: _______________
YES NO The student has adequate intelligence demonstrated by performance in age appropriate
classroom or on standardized measures of cognitive ability. (Attach copies of report card
grades or standardized test results that demonstrate this pattern.)
The student exhibits some of the following characteristics: (consider chronological age: primary
characteristics are indicated by *; provide evidence indicated in parenthesis following each characteristic).
YES NO *a. problems in learning the names of the letters of the alphabet
YES NO *b. difficulty in learning to write the alphabet correctly in sequence
YES NO c. difficulty in learning and remembering printed words.
YES NO d. reversal of letters or sequence of letters.
YES NO *e. difficulty in learning to read.
YES NO *f. difficulty in reading comprehension
YES NO *g. cramped or illegible handwriting
YES NO *h. repeated erratic spelling errors
YES NO *i. delay in spoken language
YES NO j. difficulty finding the “right” word when speaking
YES NO k. late in learning right and left and other directional components, such as
up-down, front-back, over-under, east-west.
YES NO *l. problems in learning the concept of time and temporal sequencing such as;
Yesterday, tomorrow, days of the week, or months of the year.
YES NO m. slow reading speed
YES NO n. error proneness in reading
Dyslexia Screening Indicators (continued)
YES NO o. word substitution in oral reading
YES NO A major life activity (such as learning) is substantially limited as a result of the
factors listed above that apply to the student.
___________ There are no concerns at this time.
(Teacher’s Signature) (Date)
For office use only:
_____________ Section 504 referral
_____________ The student has not met all 3 criteria for characteristics of
Dyslexia at this time.
_____________ There are no concerns at this time.
(Principal’s Signature) (Date)
Place in student’s GRAY folder designated as Bulletin 1903. REVISED 8/15