i-Screeneri-Screener Upon completion a copy of this form will be sent to your Tutor / Assessor and the Achievement Training Ltd SenCo.All information supplied within this form will follow the Achievement Training data protection policy and procedure. Learner First Name:Learner Date of Birth:Course:Learner Surname:Course Tutor:Please answer the following questions:YesNoDoes anyone in your family have dyslexia or a learning difficulty?Have you ever been told that you might have dyslexia?Do you have a dyslexia report?Have you ever had extra support at school or in class?When you were at school did you seem to be slower at reading than others in class?Do you find it hard to listen and write at the same time?Do you find it hard to listen and remember verbal instructions?Do you often feel that you know what you want to say but cannot write down on paper?Do you have difficulty reading and understanding?When you say a longer word, do you sometimes muddle it?Do you sometimes use the wrong word or forget words when speaking?Do you have difficulty with spelling?Do you struggle to meet deadlines for work in class and assignments?Are you slower to finish work than other people?Do you find it hard to concentrate in class?Have you ever had extra time for examinations or tests?Have you ever been told that you may have dyspraxia?Do you think you are clumsy?Do you have difficulty knowing left from right?Do you struggle to follow directions?Are team and ball games or practical skills like riding a bike or doing up buttons difficult for you?Have you been told you might have a problem with your sight?When reading, do words seem to move around the page?When reading, do words seem to go out of focus?When reading, do you see patterns in the writing, with big spaces, or print that appears to be too close?Learner Signature: Sign HerePlease enter your Tutor/Assessor email address:Submit Form
