Student: __________________________ School: _____________________
Teacher: _______________________ Date of Assessment: _______________
Criteria 1 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.)
Criteria 2 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