Definition of Dyslexia

Dyslexia is a specific language-based disorder of constitutional origin characterized by difficulty in single word decoding, usually reflecting insufficient phonological processing abilities. These difficulties in single word decoding are often unexpected in relation to age and other cognitive and academic abilities; they are not the result of generalized developmental disability or sensory impairment. Dyslexia is manifested by variable difficulty with different forms of language, often including, in addition to problems reading, a conspicuous problem with acquiring proficiency in writing and spelling.


Dyslexia Referral


Teachers Responsibility

Teacher Checklist
Copy of Other Testing Data including I.Q. (Cumulative Folder)
Copy of Report Card Grades (Cumulative Folder)
List intervention Strategies Used
Samples of the Students Work, including Expressive Writing
(Return all information to Sandra Burrows, Gonzales Elementary)
(All information must be complete)



(If above information is specific to dyslexia.)
Parental Notification
Parent Checklist
Screening Evaluations


Committee Decision

Not Accepted
Reg. Ed./504

At Risk for Dyslexia
Parent Notification/504

Special Ed. Referral
Reg.Teacher to initiate Special Ed. Referral


If they are unexpected for the individuals age, educational level, or cognitive abilities: (check those which apply)

_____ difficulty with the development of phonological awareness and phonological processing skills (processing the sounds of speech), including segmenting or breaking spoken words into individual sounds;

_____ difficulty reading single words in isolation;

_____ inaccurate and labored oral reading;

_____ lack of reading fluency;

_____ variable degrees of difficulty with reading comprehension;

_____ variable degrees of difficulty learning the names of letters and their associated sounds;

_____ difficulty with learning to spell;

_____ difficulty in word finding and rapid naming;

_____ variable difficulty with aspects of written composition;

_____ difficulty with learning and reproducing the alphabet in correct sequence (in either oral or written form);

_____ family history or similar problems.


Name of student____________________ Date_______________

Campus___________________ Grade_____ D.O.B.________

Referred by____________________ Position________________

Completed by_____________________ Position______________

Reason for referral


Grade _____      Retention: Yes/No      When?_____________

Excessive Absences: Yes/No

Health: Good/Fair/Poor

Hearing and Vision Screening:

Vision____pass; _____fail

Hearing____pass; _____fail

Medication: (please list)


ESL/Bilingual Yes/No When?_____________

Chapter Reading Yes/No When?_____________

Chapter Math Yes/No When?_____________

Gifted and Talented Yes/No When?_____________

Special Ed. Yes/No When?_____________

Ever referred for Special Ed. Yes/No  When?_____________


Name of student____________________


Yes No 1. Does student seem to have the intellectual ability to develop reading skills at a level equal to his/her peers?

___ ___ 2. Is student unable to read satisfactorily in spite of adequate intelligence and educational opportunity?

___ ___ 3. Is student's performance in academic tasks often inconsistent?

___ ___ 4. Are student's written assignments of poorer quality than would be expected considering his/her intellectual potential?

___ ___ 5. Can student comprehend reading at his/her grade level?

___ ___ 6. Can student explain major facts from stories read silently?

___ ___ 7. Is student's recall ability limited, especially with words and names?

___ ___ 8. Are student's math skills on grade level?

___ ___ 9. Does student have difficulty reciting the alphabet correctly in sequence (not in song or rhyme)?

___ ___ 10. Does student have difficulty in writing the alphabet correctly in sequence?

___ ___ 11. Does student have difficulty matching lower and upper case letters by name?

___ ___ 12. Does student have difficulty visually matching identical words and short phrases?

___ ___ 13. Does student have difficulty in handwriting?

___ ___ 14. Does student have trouble with drawing, writing, and copying skills?

___ ___ 15. Does student have difficulty with spelling?

___ ___ 16. Does student have difficulty discriminating similar words and letter sounds?

___ ___ 17. Does student show confusion differentiating short vowel sounds?


1. Does student demonstrate directional problems? ___ ___

2. Does student have difficulty with spatial orientation i.e., before/ after, left/right, etc.?___ ___

3. Does student demonstrate a hand preference? R__ L__ ___ ___

4. Does student demonstrate a short attention span? ___ ___

5. Does student demonstrate difficulty with coordination? ___ ___

6. Is student easily distracted from tasks? ___ ___

7. Does student exhibit signs of frustration in class? ___ ___

8. Is student frequently overly active or a disturbance in class? ___ ___

9. Is student often passive or withdrawn? ___ ___

10. Does student often forget assignments? ___ ___

11. Does student often lose papers? ___ ___

12. Does student have difficulty remembering and following directions? ___ ___

13. Does student lack organization skills? ___ ___

14. Does student show interest and motivation towards school?

Please attach and/or list the following:

_____Attach Copies of Other Testing Data including I.Q. (Cumulative Folder)

_____Attach Dopies of All Report Card Grades (Cumulative Folder)

_____Attach Samples of Students Written Work, including Expressive Writing

_____List Intervention Strategies Used

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