Learning Needs Screening Tool

Interview Date

BACKGROUND INFORMATION

NAME

BIRTH DATE

INTERVIEWER NAME

SEX

        Male               Female

 HOUSEHOLD TYPE

        Single parent                 Two parents

COMMUNITY SERVICES OFFICE (CSO)

JAS NUMBER

ETHNICITY

          African American             Asian                  Caucasian                  Hispanic/Latino             Native American

ACES NUMBER

COMPLETED YEARS OF FORMAL EDUCATION

DEGREE (S) ATTAINED

     High School Diploma           GED                Technical/vocational                 AA degree                   Other (specify):

WHAT KIND OF JOB WOULD YOU LIKE TO GET?

DO YOU HAVE EXPEREINCE IN THIS FIELD OR A RELATED FIELD?

WHAT MAKES IT HARD FOR YOU TO GET OR KEEP THIS KIND OF JOB?

WHAT WOULD HELP?

BEFORE ANSWERING THE FOLLOWING QUESTIONS, READ THE STATEMENT ALOUD ON THE BACK TO THE CLIENT

SEE INSTRUCTIONS ON BACK OF THIS PAGE

        YES     SECTION I

q         1. Have you had any problems learning in middle school or junior high?

q         2. Do you have difficulty working from a test booklet to an answer sheet:

q         3.  Do you have difficulty or experience problems working with numbers in a column?

q         4.  Do you have trouble judging distances?

q         5.  Do any family members have learning problems?

1 x ______ = ______ = Count the number of “YES’S.”  Multiply by 1.

              Section II

q        6.  Have you had any problems learning in elementary school?

q        7.  Do you have difficulty or experience problems mixing mathematical sighs (+/x)?

2 x _______ = _______ =  Count the number of “YES’S.”  Multiply by 2.

              Section III

q       8,  Do you have difficulty or experience problems filling out forms

q       9.  Did you experience difficulty memorizing numbers?

q      10.  Do you have difficulty remembers how to spell simple words you know?

3 x ______ = ______ = Count the number of “YES’S.” Multiply by 3.

                Section IV

q      11.  Do you have difficulty or experience problems taking notes ?

q      12.  Do you have difficulty or experience problems adding and subtracting small numbers in your head

q      13.  Were you ever in a special program or given extra help in school?

4 x ______ = ______ = Count the number of “YES’S.”  Multiply by 4.

_______  Total:  If 12 or more, refer for further assessment.