DYSLEXIA

SCREENING
INSTRUMENT
Kathryn B. Coon, Melissa M. Waguespack, Mary Jo Polk (1994)
Respondent Name: _______________________________________
Date of Birth: ____________________ Age: __________
Gender: __________________________
Standard: _________________________
School: ___________________________
Raters Name: ______________________
Raters Signature: ___________________
Date of Rating: _____________________
RATER: To what extent does the students
characteristics?
1 never exhibits
2 seldom exhibits
3 sometimes exhibits
4 often exhibits
5 always exhibits (Please rate all statements)

exhibit

these

__________ 1. Easily distracted

__________ 2. Forgets assignment and/or loses papers
__________ 3. Easily frustrated
__________ 4. Low self-esteem
__________ 5. Puts himself/herself down
__________ 6. Falls apart under time limits and pressure
__________ 7. Disorganized
__________ 8. Knows material one day; doesnt know it the next day
__________ 9. Knows class material but tests poorly
__________ 10. Oral reading inaccurate
__________ 11. Reverses letters and/or numbers

__________ 12. Losing ground on achievement tests

__________ 13. Poor directionally (up/down, left/right, over/under)
__________ 14. Poor sequencing skills
__________ 15. Vocabulary of written composition in NOT equal to
students spoken vocabulary
__________ 16. Poor organization of composition (Events are not in
chronological order or any discipline order organization
__________ 17. Inadequate spelling for grade level
__________ 18. Trouble following a series of directions
__________ 19. Needs information repeated
__________ 20. Poor handwriting
__________ 21. Has trouble copying
__________ 22. Unable to tell time, days of the week, months of the
year
__________ 23. Unable to tell time, days of the week, months of the
year
__________ 24. Cannot recall words, especially names
__________ 25. Production of smudged papers (erasures, mark-over)
__________ 26. Delay in verbal response
__________ 27. Doesnt anticipate consequence of behavior
__________ 28. Misplaces and loses personal items
__________ 29. Cant stay on task
__________ 30. Cant repeat information
__________ 31. Has trouble with the alphabet (learning and/or
saying)
__________ 32. Is very literal/concrete in thinking

Raters Signature __________