Examiner’s Records for Dyslexia
Humble ISD
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Humble Independent School District
Process Checklist for
(Student)
General Education Process for Identification of Students with Dyslexia
Process Activity
/ Date / Results/CommentsPart I
Data Gathering
(May be a two-step process) / Data Review
· Cumulative Folder
· Core Team File
· Teacher Observation Data Form
· Identification Profile
Writing Sample
Reading Inventory (QRI-3 or 4)
Committee Recommendation
Part II
Recommendation for Assessment / Parent Permission Documentation
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
Evaluation / District Review (if necessary)
504 Committee/Core Team/Special Service Team Recommendation/Documentation
· Characteristic Profile of Dyslexia
Part IV Placement / Determine Classroom Accommodations/ Modifications and TAKS Bundle
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 / ? / Characteristics1. / 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:
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
Student’s Name Grade Age Date of BirthPerson Being Interviewed/Surveyed Relationship Interviewer, if applicable Date
1. List three positive strengths of your child.
2. How did your child’s early language development compare to that of other children?
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
4. Describe your child’s early reading experiences at home and school.
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
6 What is your child’s attitude toward reading?
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Part II Recommendation for Assessment: Parent Information Data Form
If so, please describe.
8. Describe how your child deals with homework assignments (time, attitude, need for help…).
9. Describe any reading or learning problems experienced by family members.
10. Describe any specific illnesses, accidents, and/or allergies.
11. Describe any difficulty your child has with balance, following directions, etc.
12. Is there any additional information about your child that you would like to provide?
Please explain.
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Student Date Examiner’s Name
Humble Independent School District
Summative Report for Dyslexia Assessment
Record of Scores
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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
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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 ScoresStandard 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 / <70 / Very Poor
Guide to Interpreting TOWRE Subtest and
Total Standard Scores / Guide to Interpreting Test of Written Spelling
(TWS-4) Standard Scores
Standard Scores / Classification / Standard Scores / Classification
131-165 / Very Superior / 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 / <70 / Very Poor
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Humble Independent School District
SUMMATIVE REPORT FOR DYSLEXIA ASSESSMENT
Characteristic Profile of Dyslexia
Name Date
Campus Grade Retained: N / Y
Referral Reason:Teacher Referral Outside Evaluation
Parent Referral ARD Referral
Transfer / Standard Score / Classification * / Percentile
1. UNDERLYING CAUSE (need one or more qualifiers):
PHONOLOGICAL PROCESSING – COMPOSITE SCORE:
Phonological Awareness (CTOPP) (COMPOSITE)
Phonological Memory (CTOPP) (COMPOSITE)
Rapid Naming (CTOPP) (COMPOSITE)
2a. PRIMARY CHARACTERISTICS (need three or more qualifiers in 2a and 2b):
WORD RECOGNITION (TOWRE)
DECODING (TOWRE)
ORAL READING FLUENCY (GORT-4)
Rate (GORT-4)
Accuracy (GORT-4)
SPELLING (TWS)
2b. SECONDARY CONSEQUENCES
READING COMPREHENSION (GORT-4)
3. COGNITIVE ABILITY (must be average to above average; the student must have average ability to learn in the absence of print): Difficulties the student exhibits in reading should be unexpected in relation to the student’s other cognitive abilities and the provision of effective classroom instruction.
COEXISTING FACTORS/COMPLICATIONS: / Circle one:
Vision / Hearing / passed / failed
Teacher Reports of Classroom Concerns / yes / no
Academic Progress Reports / excellent / average / poor
Intervention (school) (attached and reviewed) / yes / no
Intervention (private) (attached and reviewed) / yes / no
Positive Family History of Reading Difficulties (suspected / diagnosed) / yes / no
Attentional Issues / suspected / diagnosed
Handwriting Legibility / excellent / average / poor
Behavioral Difficulties / reported / unreported
TAKS Scores from Grade ______/ Reading ( ) P / F / Math ( ) P / F / Writing ( ) P / F
Attendance (note excessive absences) / Grade____ # of days_____ / Grade____ # of days_____ / Grade____ # of days_____
Dyslexia is a specific learning disability that is neurological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge (Adopted by the International Dyslexia Association Board of Directors, November 12, 2002).
In order to qualify for “direct” dyslexia services in HISD, a student must exhibit one qualifier in section 1, a minimum of three qualifiers in section 2a and/or 2b, and one qualifier in section 3. (Qualifier = Below the “average” classification)
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Humble Independent School District
Summative Report for Dyslexia Assessment
Student Date of Birth Grade
Age School Date of Assessment
Compiled by
REASON FOR ASSESSMENT
TESTS ADMINISTERED
Assessment Overview
Comprehensive Test of Phonological Processing (CTOPP)
The Comprehensive Test of Phonological Processing (CTOPP) assesses three kinds of phonological processing - phonological awareness, phonological memory, and rapid naming:
o Phonological Awareness – an individual’s awareness of and access to the sound structure of his or her oral language (Mattingly, 1972).
o Phonological Memory – refers to coding information phonologically for temporary storage in working or short-term memory. When you attempt to remember a phone number you have looked up as you make your way to the phone, you are storing the number temporarily in working memory. You probably do so not by storing a visual representation of the sequence of digits (although you may be able to do this if you try), but rather by storing a phonological representation of the sounds of the digit names.