Specific Learning Difficulties – Screening Application Form for
Undergraduate Students
Confidential
This questionnaire will not be used as any part of any academic assessment and is
entirely confidential. It is solely for the purpose of providing an initial indicator of
dyslexia, dyspraxia or dyscalculia, and nothing else.
Please answer each question as accurately as possible. When you have completed this
information, you should hand this in to the Disability Service main office, room 2054 of
the Arts Building. You can contact us on 8963111 or email disab@tcd.ie
Personal Details: Please complete all of the following before submitting:
Today’s date: ___________________________________
Name: _________________________________________
School: ________________________________________
Course: ________________________________________
Student Number: ________________________________
Email Address: _________________________________
Are you already registered with the Disability Service? _______
Disability Officer _______________________________________
1. Download, complete and print out this application form.
2. Return this form to the Disability Office with a fee of €40 to cover the cost of test materials
and administration. This charge is reimbursed to students in receipt of support from the
Student Assistance Fund, or a Higher Education Grant. DS will require confirmation of
financial support from the student / College authorities.
3. Your screening request will be reviewed by a Dyslexia specialist who will contact you with an
appointment.
Disclaimer: This questionnaire forms part of a screening procedure. College cannot guarantee that it is
possible to identify all cases of dyslexia, dyspraxia or dyscalculia by this screening process. We use a
battery of tests and an assessment structure that is generally considered to be best practice, but which
cannot always provide a totally accurate result. Accordingly, not all cases of SpLD will be identified.
College does not accept responsibility in any such cases where there is a subsequent diagnosis.
Where positive indicators are identified students are advised that it may be necessary to source a full
assessment from a psychologist in order to register with the Disability Service. This may cost in the
region of €500 - €800.
Please tick YES, NO or DON’T KNOW to
each question.
Do not omit any questions.
1. Educational History
Yes
No
Don’t
know
Office
use
Have you ever been diagnosed with
dyslexia / dyspraxia / dyscalculia?
Has anyone in the past suggested to you
that you might have dyslexia / dyspraxia /
dyscalculia?
Did you receive extra learning support at
school or college?
Did you get extra time for exams at school
or college?
Have you previously had an assessment for
a specific learning difficulty?
If yes, please provide as much information
as possible about this previous
assessment, in the text box below. For
example, when did the assessment take
place, where and by whom were you
tested, do you have a copy of the dyslexia
report?
2. Sight, Hearing Speech and Language
Yes
No
Don’t
know
Office
use
Yes
No
Don’t
know
Office
use
Yes
No
Don’t
Know
Office
use
Have you ever used a coloured overlay or
had tinted lenses to help you with reading?
Do you find looking at black print on white
paper uncomfortable to read?
Do you have any current or past problems
with your hearing?
Did you have speech problems as a child or
ever see a speech therapist?
Do you sometimes forget words or use the
wrong word when speaking aloud?
3. Coordination and Organisation
Do you consider yourself to be accident
prone or clumsy?
Do you have problems playing team sports,
hand eye coordination or dancing?
Do you have difficulty knowing left from
right?
Do you struggle with directions / finding
your way to places?
Do you feel generally disorganised or
muddled?
Do you easily lose track of time?
Do you find it difficult to concentrate for
periods of time?
4. Memory
Do you find it hard to listen to and retain
verbal information / spoken instructions?
Do you get confused over dates and times
and sometimes miss appointments?
Do you feel that you have general problems
with your memory?
5. Past and Current Difficulties
Yes
No
Don’t
know
Office
use
As a child, did you find it difficult to learn to
read?
Do you have difficulties with reading now?
Do you have difficulties with spelling
accurately?
As a child, did you find it difficult to learn
your multiplication tables?
Is your handwriting untidy or difficult to
read?
Do you find it hard to make notes in
lectures?
Do you always have enough time to finish
in exams?
Do you always manage to meet deadlines
for assignments?
Do you have difficulty with planning and
structuring your written work?
Do you often feel like you know what you
want to say, but can’t get it down on paper?
Do you have difficulty proofreading and
spotting mistakes in your written work
(without a spellchecker)?
Do you have difficulty expressing yourself
verbally?
6. Family History
Yes
No
Don’t
know
Office
use
Yes
No
Don’t
know
Office
use
Do any of your family members have
dyslexia, dyspraxia or dyscalculia?
7. Reading
When reading do you find reading difficult and tiring?
read more slowly than others?
often not finish set reading tasks?
sometimes forget what you have just read?
have to read text more than once to make
sense?
accidentally add in words from another
line?
sometimes change lines?
miss out words (especially little ones)?
sometimes read words backwards (on for
no)?
lose the place?
panic and make a mess of reading aloud?
find it hard to keep your eyes on the right
place?
misread or misunderstand text?
always have to start reading from the
beginning?
have difficulty finding information in text?
forget the beginning in longer questions?
find it hard to use a dictionary or index?
find black print on white paper hard to see
clearly?
get headaches or sore eyes?
Does anything else about reading bother
you?
What?
Yes
8. Writing
When writing, do you have illegible handwriting?
set out your work poorly?
write very slowly?
grip a pen/pencil so tightly your hand hurts?
put your head down to watch the tip of the
pencil?
have difficulty getting letters to "sit" on the
lines?
mix up capital and lower case letters?
need to rest when writing at length?
find it easier to print than do 'joined up'
writing?
No
Don’t
know
Office
use
have poor spelling?
write letters or words in the wrong order?
find it hard to write ideas clearly?
find it hard to listen & take notes at the
same time?
struggle to copy accurately?
find it hard to keep up with the rest of the
class?
struggle to find the exact word you want to
use?
have difficulty finding errors and redrafting
your work?
always write as little as possible?
forget what you want to write next or write
things in the wrong order?
Does anything else about writing bother
you?
What?
Yes
9. Maths/Numbers
Maths/number work: do you find you are much slower than others to
finish?
copy numbers incorrectly?
write numbers the wrong way round (e.g.
23 for 32)?
start working from the wrong end (e.g.
adding from the left)?
sometimes carry a number the wrong way?
have problems understanding place value?
find it hard to write numbers correctly in
columns?
find it hard to get a series of steps in the
right order every
time?
do something right one day but wrong the
next day?
find it hard to estimate size etc?
mix up symbols e.g. + and x ?
have problems writing formulae correctly?
struggle to remember the names of
shapes?
have problems understanding scale?
No
Don’t
know
Office
use
have problems reading figures in the right
order?
have difficulty counting backwards?
struggle to find information in
graphs/charts?
have some difficulty telling time on a round
clock?
find it hard to guess how long it takes to so
something?
mix up direction words e.g. above/below?
struggle to get information from timetables?
find it hard to use a ruler to draw straight
lines or measure?
struggle to hold numbers in your head while
doing calculations?
have problems remembering multiplication
tables?
struggle to copy an answer accurately from
one place to another?
sometimes start a Maths problem at the
wrong place?
Is there anything else that makes Maths
hard for you?
Yes
In general, do you…
avoid reading if you can
avoid writing if you can
find it hard to finish work in time allowed
forget or lose books and equipment
find it hard to follow instructions
lose answers because your work is messy
find it hard to remember names and
messages
often put things in the wrong order
have problems judging speed and distance
have difficulty entering phone numbers in
the right order
find you are easily distracted
miss deadlines, appointments etc
tend to bump into things/people
feel confused when you find simple tasks
hard
try to hide your difficulties from others
lack self confidence
No
Don’t
know
Office
use
feel angry and frustrated at times
think of yourself as a failure
wonder if you really are stupid or mad
sometimes think you will never succeed
Is there anything you would like to add?
You have probably ticked a mixture of yes
and no boxes – this does not mean that
you are definitely dyslexic. Many people
have some of these problems, especially
when they are stressed. You could have
some problems with your eyesight or your
hearing, or perhaps English is not your first
language.
1. Handwriting Sample
This is a timed writing exercise. Use your natural handwriting and do not worry about what you say.
Give yourself 2 minutes to write a short paragraph starting with the sentence below.
Please turn over onto the back page if you run out of space. Do not exceed 2 minutes.
I chose to come to Trinity College because
Count the number of words you have written in 2 minutes and write the number in the box below.
Number of words:
sa