Dyslexia Education Center
Teacher Checklist
Student’s Name:
Date:
School:
Grade Placement:
Checklist completed by:
D.O.B.
Position:
I hereby give my permission for the release of information to the Dyslexia Education
Center. I am the parent/legal guardian of the above named student.
Parent/ Guardian Signature
Dear Teacher:
Thank you for taking the time to complete the attached questionnaire. It is an important
tool in developing a better understanding of this student’s learning differences.
1. What do you teach this student?
2. Please describe this student as you see him/her.
3. What do you feel are his/her chief educational needs?
4. Describe this student’s behavior in an academic setting.
(Please use the back of this page if you need more space)
1
Mississippi College Dyslexia Education Center
P.O. Box 4039 Clinton MS 39058
Please place an X to answer the questions YES or NO.
YES
NO_
ACHIEVEMENT
1. Does this student seem to have the intellectual ability to develop
reading skills at a level equal to his/her peers?
2. Is this student unable to read satisfactorily in spite of adequate
intelligence and educational opportunities?
3. Is this student’s performance in academic tasks often inconsistent?
4. Can this student comprehend reading at his/her grade level?
5. Can this student explain major facts from stories read silently?
6. Does this student have difficulty discriminating similar words and/or
the sounds that letters make?
7. Does this student show confusion differentiating short vowel sounds?
8. Is this student’s recall ability limited, especially with words and
names? Is response delayed more than normal?
9. Does this student have difficulty reciting (without singing) the
alphabet correctly in sequence?
10. Does this student have difficulty writing the alphabet correctly in
sequence?
11. Does this student have difficulty matching lower and upper case
letters by name?
12. Does this student have difficulty visually matching identical words
and short phrases?
13. Are this student’s written assignments of poorer quality than would be
expected considering his/her intellectual potential?
14. Does this student have difficulty with handwriting?
15. Does this student demonstrate a hand preference? R
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L
Mississippi College Dyslexia Education Center
P.O. Box 4039 Clinton MS 39058
YES
NO
16. Does this student have trouble copying notes from the board, a book or
paper correctly?
17. Does this student have difficulty with spelling?
18. Are this student’s math skills on grade level?
19. Is this student inconsistent in academic areas? (For example, one day
he/she seems to understand perfectly what they have been taught, and
the next day they act as though they have never heard of it before.)
BEHAVIOR
1. Do you often repeat instructions to this student?
2. Does this student seem to have difficulty following directions?
3. Do the parents of this student complain that they have to spend an
extraordinary amount of time to help with homework?
4. Does this student receive low grades in reading, writing, and spelling
compared to his ability to think and understand?
5. Does this student seem to have more difficulty in reading, writing, and
spelling than in most other subjects?
6. Does this student seem to enjoy reading to or with someone?
7. Does this student hesitate to read orally and/or silently in class?
8. Does this student take longer to complete assignments than his peers?
9. Is this student able to shift easily from one concept to another?
10. Does this student become confused when too much information is
presented on a page?
Please feel free to make any additional comments that would be helpful to understand this
student. PLEASE MAIL THIS TO THE ADDRESS BELOW BEFORE THE
EVALUATION DATE.
Teacher Signature:
Date:
3
Mississippi College Dyslexia Education Center
P.O. Box 4039 Clinton MS 39058