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Humble Independent School District 02/15 1 Dyslexia Process Checklist Examiner’s Records for Dyslexia

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Page 1: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 1 Dyslexia Process Checklist

Examiner’s Records for Dyslexia

Page 2: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 2 Dyslexia Process Checklist

General Education Process for Identification of Students with Dyslexia Student ___________________________________________________

Process Activity

Document using Examiner’s Records for Dyslexia

Check that the process is complete

Ste

p I

D

ata

Ga

the

rin

g

Student Educational Review (Form SER)

Intervention History Review—(attach copies of intervention documents/progress monitoring)

Teacher Observation Data (Form TIQ)

Current Writing and Work Samples

Collect Reading Assessment/Running Record—(can include QRI-3 or 4, Universal Screening Assessment, or alternate benchmark assessment)

Classroom Teacher Interventionist

Begin to complete Data Review (Form DR)

Ste

p I

I F

orm

al

Ass

ess

me

nt

Parent Consent Letter/Notification of Rights

Parent Information Data (Form PQ)

Administer Reading Assessments (Benchmark)

Comprehensive Test of Phonological Processing - 2 (CTOPP-2)

Test of Written Spelling – 5 (TWS-5)

Test of Word Reading Efficiency (TOWRE-2)

Gray Oral Reading Tests (GORT-5)

Ste

p I

II

Ev

alu

ati

on

District Review (if necessary)

504 Committee Review of Data/Determine:

Identification of Dyslexia

Eligibility under Section 504

Ste

p I

V

Pla

cem

en

t

Determine Appropriate Instructional Program and Accommodations/Modifications (if any)

Parent Notification/Placement

Permission/Documentation/Distribution of Accommodation Plan (if any)

Copy Dyslexia Information and Update (Form IUF)

(submit to District Dyslexia /Rti Coordinator)

Place Dyslexia Information and Update Form in student cum folder (Form IUF)

Teacher Meeting/General Ed. Staff

Page 3: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 3 Form: SER

Step I Data Gathering—Student Educational Review

To be completed by the Dyslexia Specialist

Student Name:

Grade:

Teacher Name:

Please print and attach the following items from Eduphoria Aware:

____Test History

____RtI Data if applicable

Please print and attach the following items from Eschool:

____Attendance History

____Current and past classroom grades

____Primary Home Language

____Discipline History

____504 information if applicable

____Special Education information if applicable

Please copy and attach the following items for the student cum:

___Any Grade Placement Committee decisions (ex. Retentions, SSI)

___Summer School Information if applicable

___English Language Learner’s Educational History (ex. Two-way, ESL etc.)

Please collect the following form the classroom teacher:

___Current DRA text fluency and running record

___Current Istation data

___Current writing and work samples

Page 4: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 4 Form: TIQ

Teacher Input Questionnaire Student Name:__________________________ Grade:__________________ Teacher Name:__________________________ Subject Taught:___________ Please return the completed questionnaire by:________________

PLEASE CHECK ALL THAT APPLY BASIC READING SKILLS AND READING COMPREHENSION _____Lacks fluency, accuracy, speed _____Repeats or re-reads words _____Problem with comprehension _____Follows with finger or pencil _____Cannot scan or summarize _____Difficulty predicting cause and effect _____Poor word attack skills _____Does not read independently _____Loses place; skips words or lines _____Assignments not completed or late _____Confuses similar letters/sounds _____Sub-vocalizes when reading _____Difficulty making inferences _____Does not comprehend main idea _____Does not recognize sight words LISTENING COMPREHENSION _____Takes no notes/poor notes _____Cannot retain information _____Trouble following directions _____Fails to pay attention _____Attends more successfully when close to the source of the sounds _____Misunderstands directions _____Confuses similar sounds _____Overloads when instructions are given SPELLING ____Spells same word different ways ____Poor sound/letter association ____Omits last letter(s) in words ____Poor phonetic spellings ____Learns spelling words for weekly tests, then forgets ____Reverses letters/sounds ____Sequential errors ____Poor punctuation/capitals MATHEMATICAL CALCULATION AND REASONING ____Reverses numbers ____Poor paper/pencil calculation ____Careless errors ____Difficulty solving word problems ____Poor math reasoning ____Confuses columns/spaces ____Forgets math facts

Page 5: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 5 Form: TIQ

____Confuses operational signs ____Does not understand abstract math concepts without concrete examples LANGUAGE SKILLS- ORAL EXPRESSION ____Hesitant speech ____Avoids verbal participation ____Poor grammar for age ____Word finding difficulties ____Forgets common words ____Poor verbal expression ____Articulation errors ____Limited vocabulary ____Does not complete statements or express complete thoughts WRITING SKILLS AND WRITTEN EXPRESSION ____Illegible penmanship ____Poor written expression ____Written assignments not completed ____Poor handwriting ____Poor drawing ____Poor punctuation ____Poor written work organization ____Difficulty copying ____Slow writer ____Detail errors ____Hand tires easily ____Poor manual skills ____Poor capitalization ____Reverses letters and numbers ____Cannot finish tasks in time BEHAVIORAL/EMOTIONAL/SOCIAL ____Hyperactive ____Often late for class/school ____Quiet and/or withdrawn ____Disorganized/forgetful ____Inconsistent behavior ____Impulsive ____Cannot generalize information ____Teased by peers ____Verbally aggressive ____Does not resolve conflict well ____Unmotivated in school ____Easily distracted ____Easily frustrated ____Immature ____Difficulty making decisions ____Unmotivated by rewards ____Little/no peer interaction

Page 6: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 6 Form: TIQ

Please list the interventions you have provided in the classroom to meet this student’s educational and/or behavioral needs. What were the results of these efforts? If they were not successful, what additional interventions were attempted? Please list any other academic concerns:

Specific Intervention:

Duration:

Frequency:

Page 7: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 7 Formal Assessment Data Overview

Record of Scores

Comprehensive Test of

Phonological Processing-2 (CTOPP-2)

Raw Scaled Descriptive

Subtests Score Score Term Core

1. Elision (EL)

2. Blending Words (BW)

3. Phoneme Isolation (PI)

4. Memory for Digits (MD)

5. Nonword Repetition (NR)

6. Rapid Digit Naming (RD)

7. Rapid Letter Naming (RL)

Supplemental

8. Blending Nonwords (BN)

9. Segmenting Nonwords (SN)

Composites EL BW PI Sums Composite of SS Scores Phonological Awareness ___ ___ ___ MD NR Phonological Memory ___ ___ RD RL Rapid Symbolic Naming ___ ___ _____________ BN SN Alternate Phonological Awareness ___ ___

Test of Written Spelling (TWS-5) Descriptive Term

Raw Score

Standard Score

Gray Oral Reading Tests (GORT-5) Story Rate Accuracy Fluency Comprehension # Score Score Score Score

1 + =

2 + =

3 + =

4 + =

5 + =

6 + =

7 + =

8 + =

9 + =

10 + =

11 + =

12 + =

13 + =

14 + =

15 + =

16 + =

Total

Scores Raw %ile Scaled Descriptive Total Rank Score Term

Rate

Accuracy

Fluency

Comprehension

Sum of Scaled Scores

Sum of Oral Reading Oral Reading Descriptive Scaled Scores %ile Rank Index (ORI) Term

Test of Word Reading Efficiency (TOWRE-2) Raw Scaled Descriptive

Subtest Score Score Term I. Sight Word Efficiency

II. Phonemic Decoding Efficiency

Sum of Scaled Scores

Total Word Reading Efficiency Index (TWRE)

+

Page 8: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 8 Formal Assessment Data Overview

Classification Overview of Assessments

Guide to Interpreting CTOPP-2 Subtest Standard Scores

Guide to Interpreting CTOPP-2 Composite Scores

Standard Scores

Descriptive Terms

Standard Scores

Descriptive Terms

17-20 Very Superior >130 Very Superior

15-16 Superior 121-130 Superior

13-14 Above Average 111-120 Above Average

8-12 Average 90-110 Average

6-7 Below Average 80-89 Below Average

4-5 Poor 70-79 Poor

1-3 Very Poor <70 Very Poor

Guide for Interpreting GORT-5 Scaled Scores

Guidelines for Interpreting the GORT-5 Oral Reading Quotient

Scaled Scores

Descriptive Terms

Index Scores

Descriptive Terms

17-20 Very Superior >130 Very Superior

15-16 Superior 121-130 Superior

13-14 Above Average 111-120 Above Average

8-12 Average 90-110 Average

6-7 Below Average 80-89 Below Average

4-5 Poor 70-79 Poor

1-3 Very Poor <70 Very Poor

Guide to Interpreting TOWRE-2 Subtest and Total Scaled Scores

Guide to Interpreting Test of Written Spelling (TWS-5) Standard Scores

Scaled Scores

Descriptive Terms

Standard Scores

Descriptive Terms

131-165 Very Superior >129 Very Superior

121-130 Superior 120-129 Superior

111-120 Above Average 110-119 Above Average

90-110 Average 90-109 Average

80-89 Below Average 80-89 Below Average

70-79 Poor 70-79 Poor

35-69 Very Poor <70 Very Poor

Page 9: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 1 Assessment Overview

Data Review and Recommendation for Dyslexia Assessment Today’s Date: Student’s Name: Campus: Grade: Student ID: Date of Referral: Examiner/Title: Referral Reason: Teacher Referral Outside Evaluation

Parent Referral Transfer ARD Referral

By regulation, the Section 504 Committee is a group of knowledgeable people. List each member attending and check the area of knowledge each provides. Use this chart to document proper attendance. Each type of knowledge must be present for the Committee to be properly constituted under Texas laws for Dyslexia purposes, and Federal law for Section 504 purposes. Note that Committee members can have more than one type of knowledge. For each member, check all boxes of knowledge that apply. (Attach an additional sheet if necessary.)

Signature of Committee Member Position/Title This member has knowledge of… The Child

The Meaning of the Evaluation Data The Reading Process Dyslexia Instruction District, State & Federal Guidelines

The Child The Meaning of the Evaluation Data The Reading Process Dyslexia Instruction District, State & Federal Guidelines

The Child The Meaning of the Evaluation Data The Reading Process Dyslexia Instruction District, State & Federal Guidelines

The Child The Meaning of the Evaluation Data The Reading Process Dyslexia Instruction District, State & Federal Guidelines

The Child The Meaning of the Evaluation Data The Reading Process Dyslexia Instruction District, State & Federal Guidelines

Data Review

Use the data gathered in Step I to determine the following: Refer to Forms SER, TQ, and Intervention Review documentation. Yes No The student has received conventional (appropriate) reading instruction. The student demonstrates characteristics of dyslexia, demonstrating difficulties in one or more areas of reading and/or the related area of spelling, including phonemic awareness and manipulation, single-word decoding, reading fluency, and learning to spell, that is unexpected for the student’s age/grade.

The student has adequate intelligence (an average ability to learn in the absence of print or in other academic areas).

The student’s lack of progress was not due to socio-cultural factors such as language differences, irregular attendance, or lack of experiential background.

Based on a preponderance of evidence, the Committee shall recommend a formal assessment for Dyslexia.

The Committee recommends a formal assessment for dyslexia.

Page 10: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 2 Assessment Overview

If no, return to Level III/Intervention Team to determine next steps.

Step I: Data Gathering (Historical Data)

Domains to Assess Data Sources Score/ Level

Check One

Strength (Above Average/

Average)

Weakness (Below Average/

Poor)

Underlying Cognitive Processes (Difficulties in phonological and phonemic awareness are typically seen in

students with dyslexia and impact a student’s ability to learn letters and the sounds associated with letters and letter combinations, learn the alphabetic principle, use the sounds of the letters and letter combinations to decode words and to accurately spell.) Phonological Processing

Phonological Awareness1

HERSI- PA Inventory or Istation Data

Other:

Rapid Symbolic Naming2 Other:

Academic Skills

Letter Knowledge- names & associated sounds

HERSI-Letter ID or Istation Data

HERSI-Dictation Task Other:

Reading real words in isolation HERSI-Word Test or Istation

Data

Other:

Decoding non-sense words Other:

Reading Fluency Fluency (Oral Fluency

Rubric)

Running Records/Istation Data

DRA

Other:

Accuracy Running Records/Istation Data

DRA Other:

Written Spelling3

HILS/WTW-Spelling Inventory Writing Samples

-Istation Data Other:

Additional Areas (may be present)

Reading Comprehension

DRA/Running Records

DBAs

State Assessment

Other:

Written Composition

Writing Samples DBAs

State Assessment Other:

1Note: Because previous effective instruction in phonological/phonemic awareness may remediate phonological awareness skills in isolation, average phonological awareness scores alone do not rule out dyslexia. Ongoing phonological processing deficits can be exhibited in word reading and/or written spelling. 2Rapid symbolic naming may or may not be weak, but if deficient, will impact a student’s ability to automatically name letters and read words and to read connected text at an appropriate rate. On-going rapid naming/fluency deficits can also be exhibited on the GORT-5 and TOWRE-2, where tasks are timed. A deficit in reading rate alone would NOT be sufficient to identify dyslexia. 3An isolated deficit in spelling would NOT be sufficient to identify dyslexia.

After Step I: Data Gathering of Historical Data is complete, refer to the statements on Assessment Overview, page 1, to determine if formal assessment for dyslexia is necessary.

Page 11: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 3 Assessment Overview

Step II: Formal Assessment

Domains to Assess Data Sources

Scaled/ Standard

Score/Level

Check One

Strength (Above

Average/ Average)

Weakness (Below Average/

Poor)

Underlying Cognitive Processes (Difficulties in phonological and phonemic awareness are typically seen in

students with dyslexia and impact a student’s ability to learn letters and the sounds associated with letters and letter combinations, learn the alphabetic principle, use the sounds of the letters and letter combinations to decode words and to accurately spell.)

Phonological Processing Phonological Awareness1

CTOPP-2 Elision, Blending Words, &

Phoneme Isolation

Phonological Memory CTOPP-2

Memory for Digits & Nonword Repetition

Rapid Naming2 CTOPP-2 Rapid Digit & Rapid Letter

Academic Skills

Letter Knowledge- names & associated sounds

Benchmark-Letter Recognition Benchmark-Picture Names

Other:

Reading real words in isolation

TOWRE-2 Sight Word Efficiency

Benchmark High Freq Words

Other:

Decoding non-sense words TOWRE-2

Phonemic Decoding Efficiency

Other:

Reading Fluency GORT-5

Oral Reading Quotient

Rate GORT-5 Rate Scaled Score

Other:

Accuracy GORT-5 Accuracy Scaled Score

Benchmark-Reading Record Other:

Fluency GORT-5 Fluency Scaled Score

Benchmark-Reading Record

Other:

Written Spelling3

TWS-5 Test of Written Spelling

Benchmark- Word Writing Other:

Additional Areas (may be present)

Reading Comprehension GORT-5 Comprehension Scaled

Score

Benchmark- Reading Record

Written Composition Other: 1Because previous effective instruction in phonological/phonemic awareness may remediate phonological awareness skills in isolation, average phonological awareness scores alone do not rule out dyslexia. Ongoing phonological processing deficits can be exhibited in word reading and/or written spelling. 2Difficulties in rapid naming may or may not be weak, but if deficient, will impact a student’s ability to automatically name letters and read words and to read connected text at an appropriate rate. On-going rapid naming/fluency deficits can also be exhibited on the GORT-4 and TOWRE, where tasks are timed. A deficit in reading rate alone would NOT be sufficient to identify dyslexia. 3An isolated deficit in spelling would NOT be sufficient to identify dyslexia.

After Step I: Data Gathering and Step II: Formal Assessment are complete, refer to page 6 to determine eligibility for dyslexia services.

Page 12: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 4 Assessment Overview

Use the data gathered in Steps I and II to determine the following: Yes No Does the student exhibit a deficit in phonological/phonemic awareness?

If the assessment data does not indicate a deficit in phonological/phonemic awareness, is there a history of the student having difficulty with phonological/phonemic awareness?

If there is a previous history, is there data to indicate intervention was provided in this area?

Does the student exhibit weaknesses in the ability to read words in isolation with automaticity?

Does the student exhibit difficulties with reading accuracy when reading connected text? Does the student exhibit difficulties with reading rate when reading connected text? Does the student exhibit academic weaknesses in spelling?

Are the academic weaknesses and the deficits in phonological awareness unexpected for the student in relation to the student’s other cognitive abilities (the ability to learn in the absence of print) and unexpected in relation to the provision of effective classroom instruction?

Texas Dyslexia Law Eligibility In making the determination of dyslexia eligibility, the committee reviewed the evaluation data from Step I and II. Based on the data, mark each area of consideration with “Agree” or “Disagree.”

Agree Disagree

The student has received conventional (appropriate) reading instruction. The student has experienced as unexpected lack of appropriate progress in the areas of reading and written spelling.

The student has adequate intelligence (has average ability to learn in the absence of print or in other academic areas.)

Based on the data gathered and reviewed from Steps I and II, the preponderance of evidence shows that the student exhibits characteristics associated with dyslexia; AND

The student’s lack of progress was not due to socio-cultural factors such as language differences, irregular attendance, or lack of experiential background.

If the Committee marked “Agree” in response to each of the preceding five statements, the student is identified as having dyslexia and is eligible for services under the Texas Dyslexia law. If the Committee answered any of the previous five statements with “Disagree,” the student is not eligible under the dyslexia law based on Blue Book criteria, and can only receive dyslexia services through action of a Section 504 Committee or ARD Committee when such services are required to provide the student with a free appropriate public education (FAPE). Note that a student can be identified as having dyslexia by Section 504 Committee or ARD Committee even if Texas Dyslexia Law requirements are not met. This is not, however, a common result.

Page 13: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 5 Assessment Overview

Committee Recommendations Based on the evaluation and

assessment data from Steps I and/or II, we believe that this student does not meet the eligibility requirements for dyslexia.

Based on the evaluation and assessment data from Steps I and II, we believe that this student does meet the eligibility requirements for dyslexia.

Based on the evaluation and assessment data from Steps I and/or II, we believe that this student:

o exhibits severe dyslexia or related disorders; or

o displays additional factors/areas complicating their dyslexia

and should be referred for assessment within the Special Education Program.

Return to Intervention Team to determine instructional

needs.

Individualized, Intensive, Multisensory Reading Instruction

(specify) _______________________________________ _______________________________________

Referral for Special Education Assessment

Determine 504 Eligibility (Refer to SSS SpEd/504 Flowchart)

Accommodations: Yes No

If yes, see 504 Accommodation Plan

Comments:

Page 14: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 6 Parent Information

DO NOT DISCARD

Humble Independent School District Dyslexia Information and Update Form *

(Place in student cum folder) Name DOB

Student ID

Originating Campus Grade Date

Examiner & Title Assessment Date Did Not Qualify Qualified (Check all that apply and complete next section.) 504 Special Education Direct Services (placed in pull-out Dyslexia Intervention Program) Monitor Only Placed in Alternate Accelerated Intervention (Please describe.) Parent Refused Services Other Transferred from another school district identified as Dyslexic. Documentation from previous

district to be kept on campus. First Lesson Date:_________________ End of Year Transition Update: Date:_______________________________ Level of Completion:_______________________ Comments regarding progress:_____________________________________________ End of Year Transition Update: Date:_______________________________ Level of Completion:_______________________ Comments regarding progress:_____________________________________________

End of Year Transition Update: Date:_______________________________ Level of Completion:_______________________ Comments regarding progress:_____________________________________________

Page 15: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 7 Parent Information

End of Year Transition Update: Date:_______________________________ Level of Completion:_______________________ Comments regarding progress:_____________________________________________

End of Year Transition Update: Date:_______________________________ Level of Completion:_______________________ Comments regarding progress:_____________________________________________ Exit from Intervention Program: Date:_____________________________ Level of Completion:_______________________ Comments regarding progress:_____________________________________________

Monitor Date:_____________________________

Monitor Date:_____________________________

Monitor Date:_____________________________

* Copy submitted to District RtI and Dyslexia Coordinator for newly identified students, ISC within 10 days of

Placement Meeting.

Page 16: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 8 Parent Information

Parent Forms and

Information

Page 17: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 9 Parent Information

Parent/Guardian Dyslexia Assessment Consent Form (School Copy) Date Sent/Mailed: Student’s Name: Campus: Grade: Student ID: Parents: Address: Home Phone: Work Phone: Dear Parents: We have carefully reviewed your child’s school records and information from teachers. At this time your child continues to exhibit difficulty in learning to read, write, and spell despite the adjustments made to his/her instructional program. The purpose of this letter is to request your permission for the Humble Independent School District to complete an assessment of your child to determine eligibility for services specifically designed for students who exhibit characteristics of dyslexia. According to TEA, this must take place as part of a referral for 504 eligibility. Please review the enclosed document entitled “Notice of Parent Rights,” which informs you of your rights under Section 504. If your child is identified as dyslexic, he/she may qualify as a student with disabilities under 504. If you CONSENT to the evaluation, please check the “consent” statement, sign and return one copy of this letter. If you REFUSE consent, please check the “refuse consent” statement, sign, and return one copy of this letter. Keep the other copy of this letter and the Notice of Parents’ Rights for future reference. When the assessment is completed, you will be invited to attend a meeting to discuss the results and, should your child qualify for these services, to assist us in planning an individualized program. If you have any questions, please feel free to contact your child’s teacher. Thank you for your assistance. Sincerely, _________________________________________ ****************************************************************************************** As the parent/legal guardian of the above referenced student, I have received notice of my Section 504 parent rights, and I understand that this is not an offer of a Special Education evaluation.

I hereby give CONSENT for the

dyslexia assessment to be administered. I hereby REFUSE consent for the

dyslexia assessment to be administered. I have received the 504 Pamphlet titled “Notice of Parent and Student Rights under 504, The

Rehabilitation Act of 1973.” _________________________________________________ Parent/Guardian’s Signature Date

Date as completed

2 copies sent to parent

Notice of Rights included

1 copy signed and returned

Page 18: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 10 Parent Information

Parent/Guardian Dyslexia Assessment Consent Form (Parent Copy)

Dear Parents: We have carefully reviewed your child’s school records and information from teachers. At this time your child continues to exhibit difficulty in learning to read, write, and spell despite the adjustments made to his/her instructional program. The purpose of this letter is to request your permission for the Humble Independent School District to complete an assessment of your child to determine eligibility for services specifically designed for students who exhibit characteristics of dyslexia. Please review the enclosed document entitled “Notice of Parent Rights,” which informs you of your rights under Section 504. If your child is identified as dyslexic, he/she may qualify as a student with disabilities under 504. If you CONSENT to the evaluation, please check the “consent” statement, sign and return one copy of this letter. If you REFUSE consent, please check the “refuse consent” statement, sign and return one copy of this letter. Keep the other copy of this letter and the Notice of Parents’ Rights for future reference. When the assessment is completed, you will be invited to attend a meeting to discuss the results and, should your child qualify for these services, to assist us in planning an individualized program. If you have any questions, please feel free to contact your child’s teacher. Thank you for your assistance. Sincerely, _____________________________________ ****************************************************************************************** As the parent/legal guardian of the above referenced student, I have received notice of my Section 504 parent rights, and I understand that this is not an offer of a Special Education evaluation.

I hereby give CONSENT for the

dyslexia assessment to be administered. I hereby REFUSE consent for the

dyslexia assessment to be administered. I have received the 504 Pamphlet titled “Notice of Parent and Student Rights under 504, The

Rehabilitation Act of 1973.” _________________________________________________ Parent/Guardian’s Signature Date

Page 19: Humble Independent School District · DRAFluency (Oral Fluency Rubric) Running Records/Istation Data Other: Accuracy Running Records/Istation Data DRA Other: Written Spelling3 HILS/WTW-Spelling

Humble Independent School District

02/15 11 Parent Information

Step II: Recommendation for Assessment: Parent Questionnaire

Student’s Name: Grade: Male Female

Campus: DOB: Parent(s): Address: Home Phone: _ Work Phone: The information requested will greatly assist the 504 Committee in evaluation of your child. If you have additional information that you want the Committee to consider (and that is not requested here) please feel free to attach additional pages. Please return this form to _______________________________ by _______________.

General Information Mother’s Name: Occupation: Father’s Name: Occupation: Do both parents live in the student’s home? Yes No If not, with whom does the student live? Name Relationship to child Other children in the home: (attach additional page if necessary) Name Age Relationship ______ _____________________ ______ _____________________ ______ _____________________ ______ _____________________ Other adults in the home:

Name Relationship to Student _______________________________________________ _____________________________ _______________________________________________ _____________________________ The primary language spoken at home is ______________________ How long has the child lived in the United States? _______________ Have there been any important changes within the family during the last three years? (For example, changes, moves, births, deaths, serious illnesses, separations, divorce) ________________________________________________________________________________________________________________________________________________________________________________________________________ Describe the student’s behavior at home with peers, siblings, neighbors, parents. (For example, is he/she generally well-behaved, passive or aggressive, social or a loner, affectionate or withdrawn, etc.) ________________________________________________________________________________________________________________________________________________________________________________________________________ Do any family members have learning problems? If yes, please explain. ________________________________________________________________________________________________________________________________________________________________________________________________________ Compared to other children in the family, this child’s development was: (check one) Slower About the same Faster

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Humble Independent School District

02/15 12 Parent Information

Has your child received any outside speech services? _____________

Has your child received outside reading and/or math tutoring? ___________

If yes, by what company and for how long?___________________________

Academic Information Please check the appropriate box for the following questions:

Yes

No

Does your child like to be read to? ____ ____ Can your child rhyme words? ____ ____ Can your child follow spoken directions? ____ ____ Can your child tell a story? ____ ____ Can your child answer questions about a story he or she has heard? ____ ____ Do you think your child is having difficulties in school? If yes, please explain: ________________________________________________________________________________________________________________________________________________________________

____

____

What do you think is causing your child’s difficulties at school? ________________________________________________________________________________________________________________________________________________________________________________________________________ When did you first notice the difficulties? ________________________________________________________________________________________________________________________________________________________________________________________________________ What is your child’s attitude towards reading? ________________________________________________________________________________________________________________________________________________________________________________________________________ Does your child receive any additional help with reading in school or outside school (current or previous)? If so, please describe. ________________________________________________________________________________________________________________________________________________________________________________________________________ Describe how your child deals with homework assignments (time, attitude, need for help…) ________________________________________________________________________________________________________________________________________________________________________________________________________ Additional Information: Is there any other information about your student or family that you would like the Section 504 Committee to consider? If so, please provide it here. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________ Signature of Parent Date

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Humble Independent School District

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Assessment Overview Information for Parents

Student Date of Birth Grade Age School Date of Assessment Compiled by REASON FOR ASSESSMENT TESTS ADMINISTERED Comprehensive Test of Phonological Processing (CTOPP-2)

The Comprehensive Test of Phonological Processing (CTOPP-2) assesses three kinds of phonological processing—phonological awareness, phonological memory, and rapid naming:

o Phonological Awareness – an individual’s awareness of and access to the sound structure of his or her oral language (Mattingly, 1972).

o Rapid Naming – refers to efficient retrieval of phonological information from long-term permanent memory.

The subtests that make up the CTOPP-2 all measure some aspect of phonological processing. The format for each subtest was selected after careful consideration of practical matters (e.g., ease of administration and scoring), and the actual items that make up the subtests were based on results of experimental investigations and statistical research. Subtests include:

o Elision (EL) – This 34-item subtest measures the extent to which an individual can say a word, then say what is left after dropping out designated sounds.

o Blending Words (BW) – This 33-item subtest measures an individual’s ability to combine sounds to form words.

o Rapid Digit Naming (RD) – This 36-item subtest measures the speed with which an individual can name numbers.

o Rapid Letter Naming (RL) – This 36-item subtest measures the speed with which an individual can name letters.

The CTOPP-2 subtests were combined in such a way as to form composites to represent the constructs of phonological awareness, phonological memory, and rapid naming. Test of Written Spelling (TWS-5)

The Test of Written Spelling (TWS-5) is a norm-referenced test of spelling. It has two equivalent forms (A and B). The test is administered using a dictated word format. The raw score is the number of items scored correct. The standard score is a transformation of raw scores that establish a common mean score and standard deviation.

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Humble Independent School District

02/15 14 Parent Information

Gray Oral Reading Tests (GORT-5) The Gray Oral Reading Tests (GORT-5) is a norm-referenced, reliable, and valid test of oral reading rate, accuracy, fluency, and comprehension. Performance on the GORT-5 yields the following scores:

o Rate – the amount of time taken by a student to read a story o Accuracy – the student’s ability to pronounce each word in the story correctly o Fluency – the student’s Rate and Accuracy Scores combined o Comprehension – the appropriateness of the student’s responses to questions about the

content of each story read o Overall Reading Ability – a combination of a student’s Fluency (i.e., Rate and Accuracy)

and Comprehension Scores The scores of rate, accuracy, fluency, and comprehension are summed and converted to scaled scores. After these scores are recorded, the sum of scaled scores is converted to the overall Oral Reading Quotient (ORQ) – the best measure of a student’s overall oral reading ability. Test of Word Reading Efficiency (TOWRE-2)

The Test of Word Reading Efficiency (TOWRE) is a measure of an individual’s ability to pronounce printed words accurately and fluently. The test measures both the ability to sound out words quickly and accurately and the ability to recognize familiar words as whole units or sight words. The TOWRE contains two subtests. The Sight Word Efficiency (SWE) subtest assess the number of real printed words that can be accurately identified within 45 seconds, whereas the Phonemic Decoding Efficiency (PDE) subtest measures the number of pronounceable printed non-words that can be accurately decodes within 45 seconds. Benchmark Assessment The Benchmark Assessment System is a standardized, comprehensive assessment that is used to measure a student’s literacy strengths and needs. Students are assessed in the following components:

o Phonological Awareness Tasks o Blending Words – Students hear and say the individual sounds in a word and then

blend the sounds to say the word. This ability helps students take words apart to solve them.

o Segmenting Words - Students say a word and then say the individual sounds separately but in sequence. This ability helps students in both spelling and decoding.

o Letter Recognition – Students say the names of the alphabet by recognizing the shapes of uppercase and lower case letters.

o High Frequency Words – Students read a list of high-frequency words. This assessment will tell the extent of the student’s knowledge of high-frequency words as well as the particular words they know. Their substitutions will tell what word parts students notice.

o Writing Picture Names – Students say words slowly and write the sounds they hear. This assessment gives information about whether students can say words slowly, think about the sounds in the words, and record some of them by remembering and writing associated letters.

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Humble Independent School District

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o Word Writing – Students write all of the words they can write within a designated time limit. This assessment will give you a rich inventory of what students can control in terms of writing.

Reading Record – Students read and talk about a series of benchmark books. This assessment gives valuable information about the student’s reading processing, fluency, and comprehension.