Part 1: Dyslexia Screening Teacher Observation Data Form

Teacher Observation Data Form for Dyslexia Data Review/Screening Cypress-Fairbanks ISD

Student ______Teacher ______Subject ______

Date _____/_____/_____ School ______Grade ______

Directions: Place checkmarks in appropriate answer columns below and Attach at least 3 recent unedited writing samples.

******* Characteristics of Dyslexia? ******* Characteristics to Consider: Yes No Reads below grade level in spite of adequate intelligence and educational opportunity Requires an inordinate amount of time to complete reading tasks Exhibits frequent letter reversals, rotations, and/or transpositions in reading, writing, or spelling Seems to have an auditory discrimination problem, sometimes confusing similar speech sounds Extreme difficulty with spelling Unusual difficulty with handwriting Difficulty copying accurately from near point, i.e, desk work Difficulty copying accurately from far point, i.e, board work Written composition content appears to be below his/her potential Difficulty completing written assignments Requires an inordinate amount of time to complete writing tasks Recall ability seems poor (this can be evidenced by difficulty with alphabet sequence, story sequence, words, names, etc.) Difficulty remembering and following directions Lacks typical organizational skills Shows some directional confusion: left/right; under/over; etc. Sometimes appears to be clumsy (bumps into objects and/or misjudges placement of objects) Lacks a preference for right or left hand writing Performance in academic tasks diminishes as he/she continues the task Performance is below the class average on TAKS, CBAs, and benchmark reading tests.

******* Expected or Unexpected? ******* Other Factors to Consider: Please consider the following factors prior to referral for a dyslexia evaluation in order to determine if difficulties are expected or unexpected. It is important to consider whether other factors are the primary reason for the child’s reading difficulties. If the following factors are not the primary reason for the child’s reading difficulties, then proceeding with a dyslexia evaluation may be warranted. Multiple sources may need to be consulted when gathering this data. (example: report card, CUM folder)

Environmental Factors Yes No Irregular attendance/frequent absences (report card, CUM folder) Transiency in elementary years (consider whether the child changes districts frequently or moves within CFISD frequently) has impacted exposure to the curriculum and prevented adequate mastery of skills (CUM folder)

1 of 2 9/2011 Cultural Factors Yes No Student speaks or is exposed to another language in the home (may or may not be identified as LEP) (Note: Complete Data Review pages 2-3.) (CUM folder, phone conversations, ask child)

Instructional Factors Yes No Lack of instruction using targeted interventions in phonics has impacted the student’s progress (teachers’ information, Intervention History)

Emotional/Behavioral Factors (including Attention) Yes No The student exhibits behavioral difficulties that interfere with learning (observation documentation) The student has a medical history and/or school history of emotional/behavioral difficulties (school nurse, office referrals)

Motivational Factors Yes No The student does not attempt classroom assignments and/or homework (report card, observation documentation) TAKS, CBAs, and benchmark scores are not consistent with the student’s grades (report cards, CBA scores)

Situational Factors Yes No The student’s academic performance has fallen dramatically within the last few months There is knowledge of situations within the student’s family that would contribute to a drop in academic performance (e.g., death of a close family member or pet, divorce of parents, parent remarrying, birth of a sibling, etc.) (conversation, journal writing)

Conclusion: Yes No Are the responses above compelling enough to indicate that this student’s classroom performance and deficits are likely due to environmental, cultural, or other factors, rather than being due to dyslexia?

What does the child do well? (Strengths should be evident in areas unrelated to reading.)

Comments:

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