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Cooper Screening

of Information Processing

(C-SIP)

This screening was developed by Dr. Richard Cooper as part of two 353 projects in 1992, one in Pennsylvania and one in South Carolina. It is not meant to be a standardized test but rather a diagnostic teaching instrument. This screening is not designed to enable teachers to diagnose learning disabilities, but it may be the first stage of an evaluation process which ultimately results in such a diagnosis. A student who answers yes to the majority of the questions on the screening may have a learning disability. This student should be referred for further testing.

The best results are obtained from students who have a good and honest knowledge of themselves. Sometimes adult students will not understand the severity of their own difficulties. For example, when asking a student about spelling, the student might believe that spelling is not a problem because he or she can write simple sentences. However, when compared to others, the student might indeed have a spelling problem. In those cases, the administrator of the screening needs to make a judgment rather than simply record the student’s response. The more one uses this screening, the more information one can obtain from it about the students. The screening takes about 50 minutes to administer for most individuals. It takes less time to administer to students with very low skills or who have limited self-awareness, and it takes more time to administer to those students who talk a great deal and try to explain each answer.

Learning disAbilities Resources (free catalog 1-800-869-8336) has a video tape of Dr. Cooper administering the C-SIP to a student followed by an explanation of the process. If you have questions about the screening and how to administer it, you can call Dr. Cooper at 610-446-6126 or contact him through our web site (www.learningdifferences.com).

Cooper Screening of Information Processing

Evaluation Date ____/____/____                     Client’s Date of Birth ____/____/____                  Age ____

Client’s Name ____________________________        Interviewer___________________________

Address ________________________________         Agency _______________________________

             _________________________________        Martial Status     S ___   M ___   D ___   W __

City ____________________________________       State ______       Zip ___________

Phone      ____________________________________           ___________________________________

Reason for the Screening        _____________________________________________________________

Referred by _________________________________ at _____________________________________

Educational History

Current grade or last grade completed __________

Schools ____________________________________________

            _____________________________________________    Best Subject ___________________

           _____________________________________________    Worst Subject __________________

Did you drop out of high school before graduation?
Yes ____

      Did you like school? (Mark yes if the person disliked school.) Yes ____

Did you ever fail a subject or repeat a grade? Yes ____

      Did you ever have to attend summer school to make up work? Yes ____

Did you have difficulty with English or Language Arts classes?
Yes ____

      Did you have difficulty with math classes? Yes ____

Were you ever in special education classes? Yes ____

      Were you ever tested for a learning disability, ADD or other problems? Yes ____

            If yes, at what age? ____________

Were you ever labeled? (e.g. LD, ADD, dyslexic, brain damaged, Yes ____

            emotionally disturbed, retarded, behavioral problem, slow learner, etc.)

What Label (s) ___________________________________________________________

Reported Problems ________________________________________________________

Summary of Educational History Yes Total # ___

Attention

Were you an active child?
Yes ____

      Were you ever called hyper or hyperactive, even informally?
Yes ____

Are you an active person now? Yes ____

      Do you have a high energy level compared to your peers? Yes ____

Do you find your mind racing so you get too many ideas or thoughts at once? Yes ____

      Do you have many tasks, projects, going on at once? Yes ____

Do you have a short attention span? Yes ____

      Do you have a tendency to day dream? Yes ____

Do you leave doors and drawers open? Yes ____

      Are you easily distracted? Yes ____

Summary of Attention Problems Yes Total # ___



Motor Skills

Do you have poor handwriting?
Yes ____

       Did you avoid playing sports as a child? Yes ____

Do you avoid playing sports now? Yes ____

       Do you find driving difficult? Yes ____

Are you a poor driver? Yes ____

       Do you frequently drop or spill things? Yes ____

Do you consider yourself clumsy? Yes ____

Do you have problems with hand/eye coordination?

Summary of motor problems Yes Total # ___



Auditory

Do you find yourself listening to more than one conversation at a time?
Yes ____

      Rhyme the word:

           CAT     ______________ ______________ __________________

           SLOW ______________ ______________ __________________

          QUICK ______________ ______________ __________________

      Person has difficulty rhyming? Yes ____

Do you often mishear words that are said to you? Yes ____

      Do you misinterpret what is said to you? Yes ____

Do you take things that are said too literally or miss double meaning or jokes? Yes ____

      Do you have difficulty paying attention to long conversations or lectures? Yes ____

Do you have difficulty hearing what one person is saying when there are

a lot of people talking? Yes ____

      Does your mind race ahead thinking about the first things that was said

      to you so you do not hear or pay attention to the rest of what was said? Yes ____

Do you have difficulty with spelling? Yes ____

Do you have difficulty reading (decoding or sounding out) unfamiliar words? Yes ____

Summary of Auditory Problems Yes Total # ___

Right/Left Discrimination

Do you confuse right and left?
Yes ____

   Check: How do you know your right and left? _______________________________

       Did you reverse letters or numbers as a child? Yes ____

Do you reverse letters or numbers now, or get phone numbers wrong?
Yes ____

       Do you have to stop and think when someone tells you to turn right or left? Yes ____

Do you have difficulty making choices (what to eat, where to go, what to do)?
Yes ____

       Do you have to stop and think which way to loosen a screw that is tight? Yes ____

Do you point one way when you mean the other or say the opposite as you point? Yes ____

      Do you have difficulty with North, South, East and West?
Yes ____

Do you find True and False questions difficult or do you read too much into questions? Yes ____

      Do you find the same is true for some multiple choice questions, or have Yes ____

      difficulty deciding between two answers which are similar?

Do you find yourself stopping for green lights? Yes ____

      Do you get lost in large buildings, malls or parking lots? Yes ____

Do you have difficulty reading maps or have to turn them to match the direction you
Yes ____

are traveling?

Summary of Right/Left Discrimination Yes Total # ___

Organizational Skills

Are you organized or disorganized?        disorganized Yes ____

      Do you tend to collect too many things?
Yes ____

Is your living or work space messy or disorganized? Yes ____

      Do you misplace or lose things, especially little things such as keys, combs Yes ____

      glasses, pens, pencils, homework, tools, utensils, etc.?

Are you often late? Yes ____

      Do you have difficulty planning or using free or unstructured time? Yes ____

Do you have difficulty organizing your ideas when you write? Yes ____

      Do you have difficulty organizing your ideas when your speak? Yes ____

Summary of Organizational Skills Yes Total # ___

Employment

Are you employed or unemployed?       unemployed
Yes ____

      Do you have difficulty learning new jobs? Yes ____

Do you have difficulty completing tasks on the job? Yes ____

      Have you ever been fired because of such problems?
Yes ____

Are you or have you been a client of Vocational Rehabilitation? Yes ____

      What types of jobs have you had?

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Summary of Employment Yes Total # ___

Emotional

Are you a moody person?
Yes ____

      Are you a nervous person? (more than most)           Yes ____

Are you a worrier? Yes ____

      Any problems with alcohol? Yes ____

Any problems with drugs?
Yes ____

       Do you, or have you suffered from test anxiety? Yes ____

Have you ever gone blank, or froze, on a test? Yes ____

      Have you ever been on medication for psychological reasons? Yes ____

                (e.g. depression, anxiety, etc.)

Have you ever been hospitalized for psychological reasons? Yes ____

      Did you ever have a severe head injury?    If yes, at what age? _______

      Did you have problems in school before the injury? _________________ Yes ____

Summary of Emotional Yes Total # ___

Social and Family

Are you shy or outgoing?                                                       shy
Yes ____

         Do you have difficulty making friends?
Yes ____

Would you say you have only a few friends? Yes ____

         Do you have difficulty getting along with members of the opposite sex?
Yes ____

Would you consider yourself a social person or a loner?       loner Yes ____

         Do you have any children?

                 If yes, how many? ________ ages? _____________

         Do they or did they have any learning problems or difficulties in school? Yes ____

Do you have any siblings?

                 If yes, how many? Brothers ___________ Sisters ______________

         Do they or did they have any learning problems or difficulties in school? Yes ____

Your father’s occupation? ______________________________

        Did he have any learning problems or difficulties in school? Yes ____

Your mother’s occupation? ______________________________

         Did she have any learning problems or difficulties in school?
Yes ____

Summary of Social and Family Yes Total # ___

Oral Communication

Do you believe that your speaking vocabulary is smaller than others?
Yes ____

         When you speak, do people have difficulty understanding what you

         are trying to communicate to them?
Yes ____

Are there any words which you have difficulty pronouncing or get you tongue-tied?
Yes ____

         Do you have a tendency to ramble, changing the topic often?
Yes ____

Do you talk too much? (Check: Does the person talk too much or take too long

to answers these questions?)
Yes ____

         Do you interrupt others?
Yes ____

Summary of Oral Communication
Yes Total # ___

Writing

Do you have difficulty with spelling? Yes ____

        Do you write a lot or only what you have to?      Only what one must
Yes ____

Is expressing your thoughts and ideas in writing difficult for you?
Yes ____

          Do you have difficulty deciding what to write about?
Yes ____

Do you have difficulty taking notes?
Yes ____

            Spelling ___ Handwriting ___ Main Idea ___ Can’t write and listen ___

         Do you speak better than you write?
Yes ____

Do you find that when you write some of your sentences are incomplete?
Yes ____

          Do you often write run-on sentences?
Yes ____

Do you have difficulty with grammar or with the less-used grammar rules?
Yes ____

          Do you have difficulty with punctuation (e.g. commas, semicolons, etc)?
Yes ____

Do you skip words when you write?
Yes ____

          Do you procrastinate on writing assignments?
Yes ____

Summary of Writing Yes Total # ___

Handwriting

Turn to the handwriting sample page and have the person do the following:

Print your full name.

Write your full name in cursive, script, sign your name.

Write a sentence about why you are here.

If not able to write that, can you write a sentence about anything.

(If the person is not able to write anything, move to the next item.)

Write or print the alphabet.

Write the numbers 1 to 20.

Draw a picture.

Is the person’s handwriting slanted up or down the page? Yes ____

         Is the person’s handwriting difficult to read?
Yes ____

Are the letters oversized for his/her age?
Yes ____

         Is the alphabet incomplete?
Yes ____

Does the person mix capital and small letters?
Yes ____

         Are there any reversals?
Yes ____

Does the sentence have any errors? Spelling ___ Missing words ___ Incomplete ___
Yes ____

         Does the person write the second digit before the 1 when writing the teen numbers?
Yes ____

Does the person hold the pen or pencil in an unusual way?
Yes ____

         Is the person’s drawing disproportionate, too simple, very unusual?
Yes ____

Notable observations __________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Summary of Handwriting
Yes Total # ___

Basic Math Skills

Do you often count on your fingers or in your head?
Yes ____

       Does the person have difficulty with the addition facts? Yes ____

       Check: 9 + 7 _____
*A__ D__ LD__ NR__ G__ CF__ CH__

                  8 + 6 _____
*A__ D__ LD__ NR__ G__ CF__ CH__

Does the person have difficulty with subtraction facts?
Yes ____

       Check: 17 - 9 _____
*A__ D__ LD__ NR__ G__ CF__ CH__

                  12 - 5 _____
*A__ D__ LD__ NR__ G__ CF__ CH__

Did you have difficulty learning the multiplication tables?
Yes ____

       Does the person have difficulty with multiplication facts?
Yes ____

       Check: 8 x 7 _____
*A__ D__ LD__ NR__ G__ CF__ CH__

                  7 x 6 _____
*A__ D__ LD__ NR__ G__ CF__ CH__

                  9 x 6 _____
*A__ D__ LD__ NR__ G__ CF__ CH__

Summary of Basic Math Skills
Yes Total # ___

*Automatic Recall__ Delay in Auto Recall __   Long Delay__   Number Relationship__

Guess__ Counting on Fingers__ Counting in Head__

Math Skills

Was it difficult for you to learn long division?
Yes ____

       Is it still difficult for you?
Yes ____

Was it difficult for you to learn fractions? Yes ____

       Is it still difficult for you? Yes ____

Was it difficult for you to learn decimals?
Yes ____

       Is it still difficult for you? Yes ____

Was it difficult for you to learn percentages? Yes ____

       Is it still difficult for you? Yes ____

Was it difficult for you to learn positive and negative numbers? Yes ____

       Is it still difficult for you? Yes ____

Were word problems difficult? Yes ____

       Have you taken algebra? If yes, did you have difficulty with algebra? Yes ____

Have you taken geometry? If yes, did you have difficulty with geometry? Yes ____

       Have you taken other math? ____________ If yes, did you have difficulty with it? Yes ____

Summary of Math Skills Yes Total # ___



Math Vocabulary

Does the person have difficulty defining:   (For young children or adults with limited ability use the terms in parenthesis)

EQUAL (Equal)       ___________________________________ Yes ____

AVERAGE (Add)          ___________________________________ Yes ____

UNIT (Subtract)   ___________________________________ Yes ____

VARIABLE (Multiply)   ___________________________________ Yes ____

COMPOUND INTEREST (Divide)     ___________________________________ Yes ____

Summary of Math Vocabulary Yes Total # ___

Reading

Do you read a lot or only what you have to? Only what you have to
Yes ____

       Do you like to read? dislikes reading
Yes ____

Are you embarrassed to read out loud?
Yes ____

       Do you tilt your head when you read or study?
Yes ____

Have the person read from the progressive reading list starting where your think the person will begin to have difficulty.

Does the person have poor word attack skills?
Yes ____

       Does the person have poor phonic skills?
Yes ____

Does the person leave off word endings?
Yes ____

       Does the person add endings to words?
Yes ____

Does the person leave off or change prefixes?
Yes ____

       Does the person misread many words?
Yes ____

Have the person read something from a book, newspaper, magazine.

Does the person add words?
Yes ____

       Does the person skip words?
Yes ____

Does the person evidence Flickering? (misreading of "a-the", "in-on" etc.)
Yes ____

       Does the person substitute words for similar words?
Yes ____

Does the person read synonyms for some words?
Yes ____

       Does the person have difficulty pronouncing words?
Yes ____

Does the person ignore punctuation?
Yes ____

       Does the person have a tracking problem?
Yes ____

Does the person use a finger or a marker as a guide?
Yes ____

       Does the person skip lines?
Yes ____

Summary of Reading
Yes Total # ___

Reading Comprehension

Do you have difficulty paraphrasing, or summarizing in your own words, what you read? Yes ____

       Do you find yourself reading whole pages without knowing what you read?
Yes ____

Are you distracted by some of the words on the page (Fireworks)?
Yes ____

       Do you have difficulty identifying the main idea when you read?
Yes ____

Do you have difficulty finding details when you read?
Yes ____

       Do you have difficulty going back and finding something that you read?
Yes ____

Are you easily distracted when you read?
Yes ____

       Do you find reading textbooks difficult?
Yes ____

Do you find that there are many words you don’t know the meaning of when you read?
Yes ____

       Do you need to read things more than once?
Yes ____

Summary of Reading Comprehension
Yes Total # ___

Vocabulary

Does the person have difficulty defining the following words?

       There are three sets of words.

       They are for different age or ability groups or to provide the administrator with many words to check a person who evidences particular difficulty with vocabulary.

       If the person cannot define the word but can use it in a sentence, mark "S" instead of Yes

Level I

           LAKE
___________________________________ S ___ Yes _____

          SLOW ___________________________________ S ___ Yes _____

          CAPTURE ___________________________________ S ___ Yes _____

          SMOKE ___________________________________ S ___ Yes _____

          REVERSE ___________________________________ S ___ Yes _____

          BEAUTIFUL
___________________________________
S ___ Yes _____

          DEVELOP
___________________________________
S ___ Yes _____

          BIOLOGY
___________________________________
S ___ Yes _____

         CAUTION
__________________________________
S ___ Yes _____

         NECESSARY
___________________________________
S ___ Yes _____

Level II

          SECTION ____________________________________ S ___ Yes _____

          PASSIVE ____________________________________ S ___ Yes _____

          DEDICATE ____________________________________ S ___ Yes _____

          MOTIVE ____________________________________ S ___ Yes _____

          FOREIGN ___________________________________ S ___ Yes _____

          ARTIFICIAL
___________________________________
S ___ Yes _____

          DEVISE
___________________________________
S ___ Yes _____

          PHILOSOPHY
___________________________________
S ___ Yes _____

          INNOVATION
___________________________________
S ___ Yes _____

          PRECISE
____________________________________
S ___ Yes _____

Level III

          THEORY ___________________________________ S ___ Yes _____

          RELUCTANT ___________________________________ S ___ Yes _____

          TRANQUILIZE ___________________________________ S ___ Yes _____

          DILEMMA ___________________________________ S ___ Yes _____

          UNANIMOUS ___________________________________ S ___ Yes _____

          EXTENSIVE
___________________________________
S ___ Yes _____

          CONTEMPLATE
___________________________________
S ___ Yes _____

          ANTHROPOLOGY
___________________________________
S ___ Yes _____

          RENAISSANCE
__________________________________
S ___ Yes _____

          COLLECTIVE
___________________________________
S ___ Yes _____

Is the person’s vocabulary underdeveloped?
Yes ____

       Is the person’s vocabulary ambiguous? Yes ____

Does the person define with another part of speech? (e.g. tranquilize - pill)
Yes ____

Summary of Vocabulary Yes Total # ___

Avoidance

Is there anything or are there any activities that you completely avoid?
Yes ____

       If yes, what? _______________________________

       Is there anything you are very fearful of in any area of your life?
Yes ____

       If yes, what? _______________________________?

Is there anything, in any area of your life, you really dislike to do Yes ____

       If yes, what? _______________________________

       Is there anything, in any area of your life, that you are unable to do?
Yes ____

       If yes, what? _______________________________

Are there any school (academic) subjects you are fearful of? Yes ____

       If yes, what? _______________________________

       Are there any school (academic) subjects you really dislike? Yes ____

       If yes, what? _______________________________

Are there any school (academic) subjects that you are unable to do?
Yes ____

       If yes, what? _______________________________

Do you ever get angry about school work?
Yes ____

       If yes, about what? _______________________________

       Angry with:   myself _____ the subject matter _____ teachers _____ school _____

Do you or did you clown around a lot in school?
Yes ____

       If yes, because you were :

       good at it _____ bored _____ distracting people from your school work _____

Summary of Avoidance Yes Total # ___

Optional Section

GOALS

What are your goals?
Short Range _____________________________________________________

                        _____________________________________________________

Long Range _____________________________________________________

                      _____________________________________________________

What do you want from this assessment?
_______________________________________________________________

What are your career plans? _______________________________________________________________

Do you plan to continue your education?
How? __________________________________________________________

Where? _________________________________________________________

PROGRESSIVE WORD LIST

Handwriting Sample Page

Observations, Notes

Screening Summary



Name _____________________________________________________________ Date________________________

Educational History 3 - 4 _____ 5 - 6 _____ 7 - 9 _____

Attention 2 - 3 _____ 4 - 6 _____ 7 - 10 _____

Motor Skills 2 - 3 _____ 4 - 6 _____ 7 - 8 _____

Auditory 2 - 3 _____ 4 - 6 _____ 7 - 10 _____

Right/Left Discrimination 3 - 5 _____ 6 - 8 _____ 9 - 13 _____

Organizational Skills 1 - 2 _____ 3 - 4 _____ 5 - 8 _____

Employment       1 _____ 2 - 3 _____ 4 - 5 _____

Emotional 2 - 3 _____ 4 - 5 _____ 6 - 10 _____

Social and Family 3 - 4 _____ 5 - 6 _____ 7 - 9 _____

Oral Communication 1 - 2 _____ 3 - 4 _____ 5 - 6 _____

Writing Skills 2 - 4 _____ 5 - 7 _____ 8 12 _____

Handwriting 2 - 3 _____ 4 - 6 _____ 7 - 10 _____

Basic Math Skills 1 - 2 _____ 3 - 5 _____

Math Skills 1 - 2 _____ 3 - 6 _____ 7 - 14 _____

Math Vocabulary       1 _____ 2 - 3 _____ 4 - 5 _____

Reading Skills 3 - 7 _____ 8 12 _____ 13 - 20 _____

Reading Comprehension 3 - 4 _____ 5 - 6 _____ 7 - 10 _____

Vocabulary 2 - 3 _____ 4 - 6 _____ 7 - 13 _____

Avoidance 2 - 3 _____ 4 - 6 _____ 7 - 9 _____

Reading List (Number correct or with little hesitation)

100 - 126 _____ 21 - 99 _____ 1 - 20 _____

Educational/Employment Plan

Reading

Spelling

Writing

Vocabulary

Math

Organization

Study Skills

Adaptations/Modifications/Assistive Devices

Produced by Richard Cooper, Ph.D.
Learning disAbilities Resources

P.O. Box 716

Bryn Mawr, PA 19010

610-446-6126

www.learningdifferences.com

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What Label (s) ___________________________________________________________
Reported Problems ________________________________________________________
Summary of Educational History	Yes Total # ___

Were you an active child?	Yes ____
Were you ever called hyper or hyperactive, even informally?		Yes ____
Are you an active person now?	Yes ____
Do you have a high energy level compared to your peers?		Yes ____
Do you find your mind racing so you get too many ideas or thoughts at once?	Yes ____
Do you have many tasks, projects, going on at once?		Yes ____
Do you have a short attention span?	Yes ____
Do you have a tendency to day dream?		Yes ____
Do you leave doors and drawers open?	Yes ____
Are you easily distracted?		Yes ____

Summary of Attention Problems	Yes Total # ___

Do you have poor handwriting?	Yes ____
Did you avoid playing sports as a child?		Yes ____
Do you avoid playing sports now?	Yes ____
Do you find driving difficult?		Yes ____
Are you a poor driver?	Yes ____
Do you frequently drop or spill things?		Yes ____
Do you consider yourself clumsy?	Yes ____
Do you have problems with hand/eye coordination?

Summary of motor problems	Yes Total # ___

Do you find yourself listening to more than one conversation at a time?	Yes ____
Rhyme the word:
CAT ______________ ______________ __________________
SLOW ______________ ______________ __________________
QUICK ______________ ______________ __________________
Person has difficulty rhyming?		Yes ____
Do you often mishear words that are said to you?	Yes ____
Do you misinterpret what is said to you?		Yes ____
Do you take things that are said too literally or miss double meaning or jokes?	Yes ____
Do you have difficulty paying attention to long conversations or lectures?		Yes ____
Do you have difficulty hearing what one person is saying when there are
a lot of people talking?	Yes ____
Does your mind race ahead thinking about the first things that was said
to you so you do not hear or pay attention to the rest of what was said?		Yes ____
Do you have difficulty with spelling?	Yes ____
Do you have difficulty reading (decoding or sounding out) unfamiliar words?		Yes ____

Summary of Auditory Problems	Yes Total # ___

Right/Left Discrimination

Do you confuse right and left?	Yes ____
Check: How do you know your right and left? _______________________________
Did you reverse letters or numbers as a child?		Yes ____
Do you reverse letters or numbers now, or get phone numbers wrong?	Yes ____
Do you have to stop and think when someone tells you to turn right or left?		Yes ____
Do you have difficulty making choices (what to eat, where to go, what to do)?	Yes ____
Do you have to stop and think which way to loosen a screw that is tight?		Yes ____
Do you point one way when you mean the other or say the opposite as you point?	Yes ____
Do you have difficulty with North, South, East and West?		Yes ____
Do you find True and False questions difficult or do you read too much into questions?	Yes ____
Do you find the same is true for some multiple choice questions, or have		Yes ____
difficulty deciding between two answers which are similar?
Do you find yourself stopping for green lights?	Yes ____
Do you get lost in large buildings, malls or parking lots?		Yes ____
Do you have difficulty reading maps or have to turn them to match the direction you	Yes ____
are traveling?

Summary of Right/Left Discrimination	Yes Total # ___

Organizational Skills

Are you organized or disorganized? disorganized	Yes ____
Do you tend to collect too many things?		Yes ____
Is your living or work space messy or disorganized?	Yes ____
Do you misplace or lose things, especially little things such as keys, combs		Yes ____
glasses, pens, pencils, homework, tools, utensils, etc.?
Are you often late?	Yes ____
Do you have difficulty planning or using free or unstructured time?		Yes ____
Do you have difficulty organizing your ideas when you write?	Yes ____
Do you have difficulty organizing your ideas when your speak?		Yes ____

Summary of Organizational Skills	Yes Total # ___

Employment

Are you employed or unemployed? unemployed	Yes ____
Do you have difficulty learning new jobs?		Yes ____
Do you have difficulty completing tasks on the job?	Yes ____
Have you ever been fired because of such problems?		Yes ____
Are you or have you been a client of Vocational Rehabilitation?	Yes ____
What types of jobs have you had?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

Summary of Employment	Yes Total # ___

Are you a moody person?	Yes ____
Are you a nervous person? (more than most)		Yes ____
Are you a worrier?	Yes ____
Any problems with alcohol?		Yes ____
Any problems with drugs?	Yes ____
Do you, or have you suffered from test anxiety?		Yes ____
Have you ever gone blank, or froze, on a test?	Yes ____
Have you ever been on medication for psychological reasons?		Yes ____
(e.g. depression, anxiety, etc.)
Have you ever been hospitalized for psychological reasons?	Yes ____
Did you ever have a severe head injury? If yes, at what age? _______
Did you have problems in school before the injury? _________________		Yes ____

Summary of Emotional	Yes Total # ___

Are you shy or outgoing? shy	Yes ____
Do you have difficulty making friends?		Yes ____
Would you say you have only a few friends?	Yes ____
Do you have difficulty getting along with members of the opposite sex?		Yes ____
Would you consider yourself a social person or a loner? loner	Yes ____
Do you have any children?
If yes, how many? ________ ages? _____________
Do they or did they have any learning problems or difficulties in school?		Yes ____
Do you have any siblings?
If yes, how many? Brothers ___________ Sisters ______________
Do they or did they have any learning problems or difficulties in school?	Yes ____
Your father’s occupation? ______________________________
Did he have any learning problems or difficulties in school?		Yes ____
Your mother’s occupation? ______________________________
Did she have any learning problems or difficulties in school?	Yes ____

Summary of Social and Family	Yes Total # ___

Do you believe that your speaking vocabulary is smaller than others?	Yes ____
When you speak, do people have difficulty understanding what you
are trying to communicate to them?		Yes ____
Are there any words which you have difficulty pronouncing or get you tongue-tied?	Yes ____
Do you have a tendency to ramble, changing the topic often?		Yes ____
Do you talk too much? (Check: Does the person talk too much or take too long
to answers these questions?)	Yes ____
Do you interrupt others?		Yes ____

Summary of Oral Communication	Yes Total # ___

Do you have difficulty with spelling?	Yes ____
Do you write a lot or only what you have to? Only what one must		Yes ____
Is expressing your thoughts and ideas in writing difficult for you?	Yes ____
Do you have difficulty deciding what to write about?		Yes ____
Do you have difficulty taking notes?	Yes ____
Spelling ___ Handwriting ___ Main Idea ___ Can’t write and listen ___
Do you speak better than you write?		Yes ____
Do you find that when you write some of your sentences are incomplete?	Yes ____
Do you often write run-on sentences?		Yes ____
Do you have difficulty with grammar or with the less-used grammar rules?	Yes ____
Do you have difficulty with punctuation (e.g. commas, semicolons, etc)?		Yes ____
Do you skip words when you write?	Yes ____
Do you procrastinate on writing assignments?		Yes ____

Summary of Writing	Yes Total # ___

Is the person’s handwriting slanted up or down the page?	Yes ____
Is the person’s handwriting difficult to read?		Yes ____
Are the letters oversized for his/her age?	Yes ____
Is the alphabet incomplete?		Yes ____
Does the person mix capital and small letters?	Yes ____
Are there any reversals?		Yes ____
Does the sentence have any errors? Spelling ___ Missing words ___ Incomplete ___	Yes ____
Does the person write the second digit before the 1 when writing the teen numbers?		Yes ____
Does the person hold the pen or pencil in an unusual way?	Yes ____
Is the person’s drawing disproportionate, too simple, very unusual?		Yes ____
Notable observations __________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Summary of Handwriting	Yes Total # ___

Do you often count on your fingers or in your head?		Yes ____
Does the person have difficulty with the addition facts?			Yes ____
Check: 9 + 7 _____	*A__ D__ LD__ NR__ G__ CF__ CH__
8 + 6 _____	*A__ D__ LD__ NR__ G__ CF__ CH__
Does the person have difficulty with subtraction facts?		Yes ____
Check: 17 - 9 _____	*A__ D__ LD__ NR__ G__ CF__ CH__
12 - 5 _____	*A__ D__ LD__ NR__ G__ CF__ CH__
Did you have difficulty learning the multiplication tables?			Yes ____
Does the person have difficulty with multiplication facts?		Yes ____
Check: 8 x 7 _____	*A__ D__ LD__ NR__ G__ CF__ CH__
7 x 6 _____	*A__ D__ LD__ NR__ G__ CF__ CH__
9 x 6 _____	*A__ D__ LD__ NR__ G__ CF__ CH__

Summary of Basic Math Skills		Yes Total # ___

*Automatic Recall__ Delay in Auto Recall __ Long Delay__ Number Relationship__
Guess__ Counting on Fingers__ Counting in Head__

Was it difficult for you to learn long division?	Yes ____
Is it still difficult for you?		Yes ____
Was it difficult for you to learn fractions?	Yes ____
Is it still difficult for you?		Yes ____
Was it difficult for you to learn decimals?	Yes ____
Is it still difficult for you?		Yes ____
Was it difficult for you to learn percentages?	Yes ____
Is it still difficult for you?		Yes ____
Was it difficult for you to learn positive and negative numbers?	Yes ____
Is it still difficult for you?		Yes ____
Were word problems difficult?	Yes ____
Have you taken algebra? If yes, did you have difficulty with algebra?		Yes ____
Have you taken geometry? If yes, did you have difficulty with geometry?	Yes ____
Have you taken other math? ____________ If yes, did you have difficulty with it?		Yes ____

Summary of Math Skills	Yes Total # ___

Does the person have difficulty defining: (For young children or adults with limited ability use the terms in parenthesis)

EQUAL	(Equal) ___________________________________	Yes ____
AVERAGE	(Add) ___________________________________		Yes ____
UNIT	(Subtract) ___________________________________	Yes ____
VARIABLE	(Multiply) ___________________________________		Yes ____
COMPOUND INTEREST	(Divide) ___________________________________	Yes ____

Summary of Math Vocabulary			Yes Total # ___

Do you read a lot or only what you have to? Only what you have to	Yes ____
Do you like to read? dislikes reading		Yes ____
Are you embarrassed to read out loud?	Yes ____
Do you tilt your head when you read or study?		Yes ____

Have the person read from the progressive reading list starting where your think the person will begin to have difficulty.

Does the person have poor word attack skills?	Yes ____
Does the person have poor phonic skills?		Yes ____
Does the person leave off word endings?	Yes ____
Does the person add endings to words?		Yes ____
Does the person leave off or change prefixes?	Yes ____
Does the person misread many words?		Yes ____

Have the person read something from a book, newspaper, magazine.

Does the person add words?	Yes ____
Does the person skip words?		Yes ____
Does the person evidence Flickering? (misreading of "a-the", "in-on" etc.)	Yes ____
Does the person substitute words for similar words?		Yes ____
Does the person read synonyms for some words?	Yes ____
Does the person have difficulty pronouncing words?		Yes ____
Does the person ignore punctuation?	Yes ____
Does the person have a tracking problem?		Yes ____
Does the person use a finger or a marker as a guide?	Yes ____
Does the person skip lines?		Yes ____

Summary of Reading	Yes Total # ___

Do you have difficulty paraphrasing, or summarizing in your own words, what you read?	Yes ____
Do you find yourself reading whole pages without knowing what you read?		Yes ____
Are you distracted by some of the words on the page (Fireworks)?	Yes ____
Do you have difficulty identifying the main idea when you read?		Yes ____
Do you have difficulty finding details when you read?	Yes ____
Do you have difficulty going back and finding something that you read?		Yes ____
Are you easily distracted when you read?	Yes ____
Do you find reading textbooks difficult?		Yes ____
Do you find that there are many words you don’t know the meaning of when you read?	Yes ____
Do you need to read things more than once?		Yes ____

Summary of Reading Comprehension	Yes Total # ___

Does the person have difficulty defining the following words?
There are three sets of words.
They are for different age or ability groups or to provide the administrator with many words to check a person who evidences particular difficulty with vocabulary.
If the person cannot define the word but can use it in a sentence, mark "S" instead of Yes

Level I

LAKE	___________________________________	S ___	Yes _____
SLOW	___________________________________	S ___	Yes _____
CAPTURE	___________________________________	S ___	Yes _____
SMOKE	___________________________________	S ___	Yes _____
REVERSE	___________________________________	S ___	Yes _____
BEAUTIFUL	___________________________________	S ___	Yes _____
DEVELOP	___________________________________	S ___	Yes _____
BIOLOGY	___________________________________	S ___	Yes _____
CAUTION	__________________________________	S ___	Yes _____
NECESSARY	___________________________________	S ___	Yes _____

Level II

SECTION	____________________________________	S ___	Yes _____
PASSIVE	____________________________________	S ___	Yes _____
DEDICATE	____________________________________	S ___	Yes _____
MOTIVE	____________________________________	S ___	Yes _____
FOREIGN	___________________________________	S ___	Yes _____
ARTIFICIAL	___________________________________	S ___	Yes _____
DEVISE	___________________________________	S ___	Yes _____
PHILOSOPHY	___________________________________	S ___	Yes _____
INNOVATION	___________________________________	S ___	Yes _____
PRECISE	____________________________________	S ___	Yes _____

Level III

THEORY	___________________________________	S ___	Yes _____
RELUCTANT	___________________________________	S ___	Yes _____
TRANQUILIZE	___________________________________	S ___	Yes _____
DILEMMA	___________________________________	S ___	Yes _____
UNANIMOUS	___________________________________	S ___	Yes _____
EXTENSIVE	___________________________________	S ___	Yes _____
CONTEMPLATE	___________________________________	S ___	Yes _____
ANTHROPOLOGY	___________________________________	S ___	Yes _____
RENAISSANCE	__________________________________	S ___	Yes _____
COLLECTIVE	___________________________________	S ___	Yes _____

Is the person’s vocabulary underdeveloped?	Yes ____
Is the person’s vocabulary ambiguous?		Yes ____
Does the person define with another part of speech? (e.g. tranquilize - pill)	Yes ____

Summary of Vocabulary	Yes Total # ___

Is there anything or are there any activities that you completely avoid?	Yes ____
If yes, what? _______________________________

Is there anything you are very fearful of in any area of your life?		Yes ____
If yes, what? _______________________________?

Is there anything, in any area of your life, you really dislike to do	Yes ____
If yes, what? _______________________________

Is there anything, in any area of your life, that you are unable to do?		Yes ____
If yes, what? _______________________________

Are there any school (academic) subjects you are fearful of?	Yes ____
If yes, what? _______________________________

Are there any school (academic) subjects you really dislike?		Yes ____
If yes, what? _______________________________

Are there any school (academic) subjects that you are unable to do?	Yes ____
If yes, what? _______________________________

Do you ever get angry about school work?		Yes ____
If yes, about what? _______________________________
Angry with: myself _____ the subject matter _____ teachers _____ school _____

Do you or did you clown around a lot in school?	Yes ____
If yes, because you were :
good at it _____ bored _____ distracting people from your school work _____

Summary of Avoidance	Yes Total # ___

What are your goals?	Short Range _____________________________________________________

	_____________________________________________________

	Long Range _____________________________________________________

	_____________________________________________________

What do you want from this assessment?	_______________________________________________________________

What are your career plans?	_______________________________________________________________

Do you plan to continue your education?	How? __________________________________________________________

	Where? _________________________________________________________

Screening Summary

Name _____________________________________________________________ Date________________________
Educational History	3 - 4 _____	5 - 6 _____	7 - 9 _____
Attention	2 - 3 _____	4 - 6 _____	7 - 10 _____
Motor Skills	2 - 3 _____	4 - 6 _____	7 - 8 _____
Auditory	2 - 3 _____	4 - 6 _____	7 - 10 _____
Right/Left Discrimination	3 - 5 _____	6 - 8 _____	9 - 13 _____
Organizational Skills	1 - 2 _____	3 - 4 _____	5 - 8 _____
Employment	1 _____	2 - 3 _____	4 - 5 _____
Emotional	2 - 3 _____	4 - 5 _____	6 - 10 _____
Social and Family	3 - 4 _____	5 - 6 _____	7 - 9 _____
Oral Communication	1 - 2 _____	3 - 4 _____	5 - 6 _____
Writing Skills	2 - 4 _____	5 - 7 _____	8 12 _____
Handwriting	2 - 3 _____	4 - 6 _____	7 - 10 _____
Basic Math Skills		1 - 2 _____	3 - 5 _____
Math Skills	1 - 2 _____	3 - 6 _____	7 - 14 _____
Math Vocabulary	1 _____	2 - 3 _____	4 - 5 _____
Reading Skills	3 - 7 _____	8 12 _____	13 - 20 _____
Reading Comprehension	3 - 4 _____	5 - 6 _____	7 - 10 _____
Vocabulary	2 - 3 _____	4 - 6 _____	7 - 13 _____
Avoidance	2 - 3 _____	4 - 6 _____	7 - 9 _____
Reading List (Number correct or with little hesitation)
	100 - 126 _____	21 - 99 _____	1 - 20 _____