Please provide the following contact information:

Disability Programs and Services Learning Disability Checklist

Name

Department

Extension

Classroom

Counseling Session

Success Center

Other:

Where have you observed the student?

There are apparent basic skills weaknesses.

Please mark all of the behaviors that you have observed. If you haven't observed the behavior, please leave it blank.

Penmanship is very sloppy despite no obvious physical cause.

Spelling difficulties show letter or whole word reversals, letter inversions, or scrambling of letters.

In speech, grammar seems adequate, but in writing multiple grammatical errors are noted.

Number and/or mathematical operation reversals are self-reported.

The student seems unable to concentrate for an adequate period of time.

Student seems unable to adequately plan study time.

Student reports severe test anxiety.

Lecture notes are inadequate.

Assessment scores show a weakness in one or two of the basic skills areas.

There is a clustering of less than satisfactory grades in classes that emphasize one or two of the basic skills areas.

The student is avoiding classes that tap one or two of the basic skills areas.

The student reports weakness in one or two of the basic skills areas.

The student reports memory difficulties.

The student reports poor study skills despite having taken a study skills class.

In tutoring situations there are apparent basic skills weaknesses.

Spelling difficulties are self-reported.

Letter or word reversals or inversions are self-reported.

BASIC SKILLS/FOUNDATION SKILLS

REVERSALS

SELF REPORTED

If two or more of the above items are checked, the student MAY have a learning disability. Please consider providing the following student information so that services may be offered to the student:

Student Name

Student ID*

OTHER

Number and/or mathematical operation reversals are observed.

marks "b" when the answer is "d" and "d" when the answer is "b."

In multiple choice tests (especially when lower case letters are used for the options) the student frequently

*Required field.