Dyslexia Screening Student Intake Form

Dyslexia Screening Student Intake Form

Dyslexia Screening Student Intake Form

UCD Dublin

Access Centre Disability Support

James Joyce Library, Level 1

Belfield

Dublin 4

The information contained in this form is strictly confidential

Dear Student,

We at the Access Centre would like to welcome you to participate in the Access Centre Dyslexia Screening service. This service is available to all registered students at UCD. Students may self-refer or attend as the result of a referral from a source within UCD. This form is used solely for the purposes of providing an initial indicator for dyslexia and does not constitute a diagnosis or entitle the student to supports from UCD Access Centre Disability Support. Your form will be reviewed and if it is deemed necessary that further assessments are needed, you will be asked to make an appointment for further screening.

The first part of the screening process is the ‘Dyslexia Screening Student Intake Form’. It is your responsibility to complete the form and return it in a timely fashion to UCD Access Centre Disability Support office with any relevant supporting documents. Please complete the form in your own handwriting. If you have any questions about this form please do not hesitate to make contact with the Access Centre on 01 716 7565.

INSTRUCTIONS FOR COMPLETING FORM

• It is your responsibility to complete this form and return it within two weeks, with any relevant documents, to the Access Centre Disability Support Office.

• You may need to consult with parents and family members in order to answer some of the questions.

• If you have received this form in an email or downloaded it from the Access Centre website please print it and complete the form in your own handwriting.

• All information contained in this form is confidential and compliant with Data Protection Acts.

Please fill in the information below

Contact Information

1. Student Name:

1. Student Number:

1. Date of Birth:

1. Age:

1. Male/Female:

1. Home Phone:

1. Mobile Phone:

1. UCD email

1. Term Address:

1. Permanent Address

Current Academic Information

1. What is your Programme of Study?

1. Please fill in the modules you are currently taking:

/ 1.
2.
3.
4.
5.
6.

1. Are you studying at undergraduate or postgraduate level?

/ Undergraduate
Postgraduate

1. What year are you in?

/ 1st
2nd
3rd
4th

1. Who referred you for screening?

/ Self
Lecturer/Tutor
Student Health
Student Advisors
Other ______

1. Please tick any difficulties (as related to learning) that you are currently experiencing.

/ Note-taking
Time needed to complete assignments
Spelling
Study Skills
Speed of reading/writing
Listening Comprehension
Essay Writing
Time Management
Other______

1. While studying at UCD have you accessed any of the following:

/ Assistance from Lecturers/tutors
a)Very Helpful
b)Helpful
c)Not Helpful
Academic Writing Centre
d)Very Helpful
e)Helpful
f)Not Helpful
Maths Support Centre
a)Very Helpful
b)Helpful
c)Not Helpful
Study Skills Modules
a)Very Helpful
b)Helpful
c)Not Helpful
Grinds
a)Very Helpful
b)Helpful
c)Not Helpful
Assistance from Family or Friends
a)Very Helpful
b)Helpful
c)Not Helpful

1. Compared to your classmates, does it take you more time to complete readings and assignments?

/ Yes
No

1. How often do you attend the following?

/

1. Lectures

Always
Sometimes
Rarely

1. Tutorials

Always
Sometimes
Rarely

1. Practical Labs

Always
Sometimes
Rarely

1. Did you attend any other third level college prior to UCD?

/ Yes
No
If yes, please state the college and how long you attended:
______

STRATEGIES FOR ACTIVE LEARNING

Please tick

1. I am determined. I work hard to find ways to succeed.

/ Never
Sometimes
Often

1. I will work for long periods of time on problems.

/ Never
Sometimes
Often

1. I seek help when I don’t understand coursework.

/ Never
Sometimes
Often

1. I work much harder than my peers.

/ Never
Sometimes
Often

1. I often stay in and study rather than socialising.

/ Never
Sometimes
Often

1. I know how I learn best and when I learn best.

/ Never
Sometimes
Often

1. When I study I make summary notes, mind maps, diagrams, etc.

/ Never
Sometimes
Often

1. I test my memory and understanding at regular intervals when studying.

/ Never
Sometimes
Often

1. I take regular breaks and monitor concentration when studying.

/ Never
Sometimes
Often

1. I try to attend all lectures and tutorials.

/ Never
Sometimes
Often

1. I repeat material aloud to be memorised, and write out key points.

/ Never
Sometimes
Often

EDUCATIONAL HISTORY

1. Have you previously been assessed for learning difficulties?

/ No
Yes, if yes by whom?
______

1. Do you have a written report from this assessment?

/ No
Yes, if yes please attach.

1. How many schools did you attend as a child?

/ Number of Primary Schools ______
Number of Secondary Schools ______

1. Please list the school(s) you attended.

/

1. ______

1. ______

1. ______

1. Did you repeat a year at primary or secondary school?

/ Yes
No
If yes, what years? ______

1. Did you experience a difficulty learning any of the following in school?

/ Reading
Writing
Spelling
Maths
Comment:
______
______
______

1. Did you receive any of the following at school?

/ Special Education Resource Teacher
Exam Accommodation
Learning Support
Extra Tuition

1. Did you require extra help outside of school?

/ Private Grinds
Family/Friends
Grind School:______

1. Did you have frequent and/or extended absences from school?

/ Yes
No
Comment:
______
______
______

1. Compared to your classmates, how much time and effort did you put into your studies in secondary school?

/ Less time and effort
The same amount of time and effort
More time and effort
Comment:______
______
______

1. In secondary school what type of assignments did you do better on?

/ Exams
Take home assignments/essays/homework

1. What were you favourite subjects in school? Please list.

/

1. ______
2. ______
3. ______
4. ______

1. What were your least favourite subjects in school? Please list.

/

1. ______
2. ______
3. ______
4. ______

FAMILY HISTORY

1. Has anyone in your family been assessed as having a learning disability?

/ No
Yes, if yes what is the nature of their learning disability?
______
______
______

1. What language is normally spoken at home?

/ ______

1. Is your family bilingual?

/ No
Yes

1. Did you attend an all-Irish or other language school?

/ No
Yes

1. If you answered yes to question 4: did you experience any of the following?

/ Learning to read in your first language
Learning to write in your first language
Learning maths in your first language

MEDICAL HISTORY

1. Did you reach developmental milestones within normal limits (crawling, walking, talking etc.

/ No
Yes
Don’t know
Comment:______

1. With which hand do you write?

/ Left
Right
Both

1. Have you ever had the following checked?

/ Eyesight
Hearing

TALENT AND ABILITIES

Please rate your ability to do the following activities.

1. Art

/ Poor
Average
Good

1. Music

/ Poor
Average
Good

1. Drama

/ Poor
Average
Good

1. Creative Writing

/ Poor
Average
Good

1. Dancing

/ Poor
Average
Good

1. Woodcraft/Crafts

/ Poor
Average
Good

1. Using a computer

/ Poor
Average
Good

1. Speaking in public

/ Poor
Average
Good

1. Other

/ ______

ADDITIONAL INFORMATION

Please detail any other information you feel may be relevant in the space provided. / ______
______
______
______
______
______
______
______
______

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