Dyslexia Teacher Questionnaire/ Referral

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Adapted from the Teacher Observation Questionnaire for Dyslexia, Texas Scottish Rite Hospital for Children

Email *

Student Name *

Student Date of Birth *

YYYY

Describe Reason for Referral. Be specific about concerns. *

Describe Tier 1 instructional approaches and the student's response within the last year: *

Describe Tier 2 instructional approaches and the student's response within the last year: *

Does this student currently receive Tier 3 instructions such as SPED or related services? Please list all:

Has this student ever been retained? If so what year?

Describe student attendance within the last year:

Excellent

Fair

Poor

Clear selection

Current Grade Level *

Clear form

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