LRSD Parent Interview updated 08/18/19
Parent Interview for a Level 1 Screener
To the parents/guardians of ___________________________ Date: ______________
As a part of our reading instruction, we conduct assessments to determine your child’s
strengths and weaknesses so we can make informed decisions about education. You are
receiving this letter because part of our reading assessment showed some indicators of risk for
reading. Per Arkansas Act 1268, the LRSD screens all K-2 students and students in grade 3-12
who show possible characteristics of dyslexia as indicated by a teacher. This does NOT mean
that your child DOES have dyslexia or characteristics of dyslexia. It only indicates that our
initial screening showed indicators and further screening is needed to determine next steps.
This interview will be used as a part of a Level 1 Screener to gather additional
information in your child’s skills in some or all of the following: alphabet knowledge,
phonemic awareness, phonics, sound-symbol recognition, decoding, rapid naming, and/ or
encoding (spelling). We may also gather assessment data for listening comprehension,
vocabulary, oral expression, written expression, handwriting, math, so the school can
determine how best to meet your child’s instructional needs. When all components have
been completed, you will be notified of the results and be asked to participate in a discussion
of next steps. To learn more about characteristics of dyslexia visit: https://ed.ted.com and
watch the video, What is Dyslexia?
If you would like to schedule a phone conference to discuss initial screening and
complete this interview, please return this page of the interview, or send me an email with
the following information:
Best phone number to reach you at: _______________________________
Times you are available to talk on the phone:
1st Choice ___________________________________
2nd Choice __________________________________
3rd Choice ___________________________________
I will do my best to be available to call at one of these times. If I am not able to contact
you at any of these times, I will call and leave a message with other options.
Sincerely,
________________________ _______________________ ________________________
Name Position Phone/ Email
Adapted from the Parent Interview for Dyslexia, Texas Scottish Rite Hospital for Children 1
LRSD Parent Interview updated 02/20/19
Completion of this form indicates the parent has been informed that a Level 1 dyslexia
screener will be completed for their child.
Person Completing this Form: _______________________ Date completed: ______________
Parent participated: ❑ In person ❑ via phone ❑ Other: __________________________________
Student Name: _________________ Date of Birth: ____________ ID Number: _____________
Grade: _____ School: __________________ Classroom Teacher (K-5) ____________________
Check the answer to the following questions regarding the student.
Family History Yes No
Learning Problems
Father
Mother
Sibling
Physical History of Student
Chronically ill
Extremely high fever
Physical problems causing difficulty learning
Currently taking medication
Trouble hearing
Trouble seeing
Check the term indicating the degree of your concern for the student regarding each skill area.
Skill Area Rarely Often
Phonological Awareness
Difficulty recognizing or reproducing rhyming words
Difficulty naming the first or last sound in a word
Difficulty blending sounds together to make a word
Alphabet
Difficulty learning or recalling names of letters
Difficulty learning or recalling sounds of letters
Decoding and Word Recognition
Difficulty sounding out unfamiliar words
Difficulty reading words accurately
Fluency
Makes frequent reading errors
Reads with hesitations
Adapted from the Parent Interview for Dyslexia, Texas Scottish Rite Hospital for Children 2
LRSD Parent Interview updated 02/20/19
Reads slowly
Spelling
Difficulty memorizing words for spelling tests
Difficulty spelling words correctly
Comprehension
Difficulty understanding what he/she reads
Difficulty answering textbook questions
Written Expression
Difficulty writing sentences correctly
Difficulty writing stories and reports
Cognitive/Academic Ability
Needs many repetitions to learn something new
Has difficulty with math facts
Has trouble with math word problems even when they are read aloud
Has reading difficulties unexpected compared to other abilities
Oral Language
When listening…difficulty understanding verbal directions
When listening…difficulty understanding stories read to him/her
When speaking…weak or limited oral vocabulary
When speaking…difficulty finding the right word
When speaking…difficulty speaking with correct grammar
When speaking…difficulty explaining ideas or elaborating on thoughts
Attention
Displays difficulty organizing time and materials
Is easily distracted by sights or sounds
Does many things too quickly
Is often overactive or fidgety
Is inconsistent with production of classwork or homework assignments
Needs direct supervision to complete homework
Handwriting
Is slow with handwriting and copying tasks
Displays overall poor quality/illegible handwriting on written assignments
Upon completion of this form, return to your school’s dyslexia contact or your child's classroom teacher
to continue the Level 1 Screening process. When all components are completed, the team must meet
to discuss results, inform the parent of results, and complete next steps. For more information, please
see the Arkansas Dyslexia Resource Guide.
Adapted from the Parent Interview for Dyslexia, Texas Scottish Rite Hospital for Children 3
