Answer every section once for each person. If you are a parent, teacher, or support worker, observe the learner carefully before responding. All information is confidential and used only to generate personalized guidance.
Name or identifier (you may use initials or pseudonym)
Date of birth
Role of person completing this form
Self (adult learner)
Parent/Caregiver
Teacher/Tutor
Therapist/Clinician
Workplace mentor
Other
Primary languages spoken at home or in learning environments
Has the learner ever received any formal diagnosis related to learning, attention, or neurodevelopment?
Please list diagnoses, year given, and by whom
Skip this section if you lack reliable childhood records. Where unsure, select 'No information' rather than guessing.
Spoke first meaningful words
Before 12 months
12-18 months
18-24 months
After 24 months
No information
Combined words into simple sentences
Before 24 months
24-30 months
30-36 months
After 36 months
No information
Frequent ear infections or hearing concerns under age 5?
Difficulty with rhyme games (e.g., cat-hat) in preschool years?
Trouble learning to hop, skip, or catch a ball compared to peers?
Indicate how often each statement applies when the learner reads or writes
Never | Rarely | Sometimes | Often | Always | |
|---|---|---|---|---|---|
Slow, effortful reading even for age-appropriate texts | |||||
Frequently loses place on page or skips lines | |||||
Substitutes similar-looking words (e.g., 'house' for 'horse') | |||||
Spells same word inconsistently in one piece of writing | |||||
Avoids reading aloud or shows visible anxiety when asked |
Current reading level compared to same-age peers
Well above average
Slightly above
Average
Slightly below
Well below
Not sure
Which compensations does the learner already use? (Select all that apply)
Text-to-speech software
Audiobooks
Colored overlays or tinted glasses
Extra time on tests
Peer reader
None of the above
Rate the learner's consistent difficulties
No difficulty | Mild | Moderate | Severe | Not applicable | |
|---|---|---|---|---|---|
Recalling basic number facts (addition, times tables) | |||||
Understanding place value (units, tens, hundreds) | |||||
Estimating quantities (how many sweets in jar) | |||||
Reading analog clocks quickly | |||||
Handling money and calculating change |
Does the learner reverse or confuse numbers (e.g., 15 vs 51)?
Describe any strategies that have helped (e.g., using manipulatives, drawing pictures)
Rate the following challenges
Not observed | Mild | Moderate | Severe | |
|---|---|---|---|---|
Illegible or very slow handwriting | ||||
Inconsistent spacing between words or letters | ||||
Difficulty copying from board or screen | ||||
Trouble with fine-motor tasks (tying shoes, buttoning) | ||||
Poor sense of direction or map reading |
Does the learner grip pen/pencil very hard or complain of hand pain?
Frequently bumps into objects or appears clumsy?
Executive functions include planning, organising, starting tasks, staying focused, and remembering instructions.
Rate from 1 (no problem) to 5 (daily impairment)
Easily distracted by background noise or movement | |
Forgets multi-step instructions without reminders | |
Starts tasks but rarely finishes without supervision | |
Loses personal items (pens, keys, phone) regularly | |
Struggles to estimate how long activities take |
Typical sleep duration per night
Less than 5 h
5-6 h
6-7 h
7-8 h
More than 8 h
Highly variable
Snores loudly or has pauses in breathing during sleep (observed)?
Overall, how does the learner feel about school/work?
Indicate frequency of each feeling
Never | Rarely | Sometimes | Often | Daily | |
|---|---|---|---|---|---|
Anxiety before tests or presentations | |||||
Sadness or hopelessness about academic progress | |||||
Frustration with teachers, peers, or family | |||||
Withdrawal from social activities | |||||
Physical symptoms (headaches, stomach-aches) before learning tasks |
Has the learner ever been bullied or teased because of school struggles?
List any coping strategies already used (deep breathing, talking to friend, etc.)
Select sensory sensitivities that disrupt learning
Bright fluorescent lights
Scratchy clothing tags
Strong food smells
Echoing sounds
Crowded hallways
None observed
Prefers to sit at the edge of classroom or near exit?
Noise tolerance during homework
Complete silence
Low background music
Moderate household noise
High noise is fine
Varies daily
Describe hobbies or activities where the learner excels (e.g., Lego building, drama, coding, caring for animals)
Rank these learning preference modalities (drag to order: 1 = most preferred)
Listening to spoken explanations | |
Watching videos or demonstrations | |
Reading text | |
Hands-on practice | |
Teaching others |
Note any cultural or community practices that influence views on learning differences (optional but helpful for sensitive support)
Reliable access to internet at home or in community?
Which devices does the learner regularly use? (Select all)
Basic mobile phone
Smartphone
Tablet
Laptop/Desktop
School-provided Chromebook
Braille notetaker
AAC device
None
Ever used speech-to-text (voice typing)?
How helpful was it?
Very unhelpful
Unhelpful
Neutral
Helpful
Very helpful
Ever used mind-mapping or visual-organiser apps?
Which app and what worked/did not work?
Record each accommodation tried and its outcome
Accommodation (e.g., extra time, quiet room) | Month/Year started | Weeks used | Result | Comments | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Extra time (25%) | 2/1/2024 | 12 | Helped a lot | Used for all written tests | |
2 | Quiet separate room | 2/1/2024 | 12 | Helped a little | Feels isolated, prefers small group | |
3 | ||||||
4 | ||||||
5 | ||||||
6 | ||||||
7 | ||||||
8 | ||||||
9 | ||||||
10 |
Vision checked by specialist within past 24 months?
Hearing screened within past 24 months?
Current medical conditions that may impact learning
Epilepsy
Diabetes
Thyroid disorder
Depression/Anxiety disorder
Autism spectrum
Cerebral palsy
Traumatic brain injury
None of the above
List any medications taken regularly and main side-effects noticed (e.g., drowsiness, faster heartbeat)
Any blood relative diagnosed with dyslexia, ADHD, or autism?
Parents or siblings struggled in school despite normal intelligence?
Brief family history (optional):
Rate availability of support (5 stars = excellent)
Access to special-needs teacher or coordinator | |
Family encouragement and involvement | |
Peer study groups or mentors | |
Community organisations or online forums | |
Financial resources for assessments or tools |
Describe biggest barrier right now (e.g., cost, long waitlists, stigma, lack of information)
Setting clear goals helps choose the right accommodations and measure progress.
Top three academic or workplace goals for the next 12 months (e.g., pass secondary maths, write reports independently, complete apprenticeship coursework)
Preferred timeline for formal assessment (if indicated)
Within 1 month
1-3 months
3-6 months
6-12 months
No interest in formal assessment
Would you like information on low-cost or free screening services?
You have reached the end. Review your answers for completeness. This checklist is not a diagnosis; it highlights patterns that may benefit from professional follow-up.
I consent to anonymous data storage for research and service improvement (no identifying names are stored).
Signature of person completing this form and today's date
Analysis for Learning Disability Screening & Support Checklist
Important Note: This analysis provides strategic insights to help you get the most from your form's submission data for powerful follow-up actions and better outcomes. Please remove this content before publishing the form to the public.
The Comprehensive Learning Disability Screening & Support Checklist is a best-practice example of a multi-domain, life-span screening tool. By spanning developmental history, academic skills, executive function, sensory processing, social-emotional health, and environmental factors, it captures the holistic picture necessary to distinguish a true learning disability from other explanations (e.g., sensory loss, second-language influence, anxiety, or inadequate instruction). The matrix-style rating scales reduce rater fatigue and produce interval-level data that can be trended over time, while the built-in conditional logic (e.g., speech-to-text usefulness only appears if the tool was used) keeps the respondent experience short and relevant. Finally, the form embeds strength-based questions—hobbies, learning preferences, technology access—so that recommendations are not purely deficit-focused; this aligns with modern neuro-diversity-affirming practice and increases respondent engagement.
From a data-quality standpoint, the form balances comprehensiveness with usability. Mandatory fields are limited to three demographic items plus the goals question, ensuring that anonymised longitudinal research can still be conducted while keeping the barrier-to-completion low. Open-text boxes are paired with placeholder examples, which nudges richer, more actionable answers. The inclusion of a consent checkbox for anonymous research storage anticipates GDPR/HIPAA considerations and builds trust. Overall, the structure supports high completion rates while still gathering nuanced qualitative data that can guide next steps for formal assessment or classroom accommodations.
Purpose: A consistent yet privacy-preserving identifier is essential for three reasons: (1) it allows the same learner to be re-screened months later so progress can be tracked, (2) it prevents duplicate submissions when parents and teachers both complete the checklist for one child, and (3) it enables secure linkage to external assessment records if the family later uploads a psycho-educational report. By explicitly permitting initials or pseudonyms, the form respects cultural or safety concerns where full names may deter participation.
Effective Design: The single-line text box is limited by front-end character constraints, discouraging essay-style answers that could indirectly reveal identity. The adjacent help text normalises anonymity, which increases truthful disclosure from adults who may fear stigma in workplace contexts. Because the field is placed early, it also signals to users that the entire tool is privacy-conscious, improving trust and completion.
Data Collection Implications: Because the identifier is not validated against official documents, there is a small risk of alias collision or forgotten pseudonyms. However, for a screening (not diagnostic) tool this is acceptable; the benefits of wider uptake outweigh the need for perfect identity fidelity. Researchers can still cluster longitudinal records statistically using additional quasi-identifiers (DOB month/year, role of respondent) without ever storing personally identifiable information.
User Experience Considerations: Users completing the form on behalf of someone else (e.g., a teacher with 30 students) can enter shorthand such as "Student A" without cognitive load. Autocomplete is disabled on this field to avoid accidentally populating the learner’s legal name, a subtle but important protective feature for shared devices.
Purpose: Age is the critical denominator when interpreting symptom severity; what is flagged as "delayed" for a 6-year-old may be typical for a 4-year-old. DOB also drives age-normed scoring algorithms that convert raw frequency ratings into risk percentiles. Finally, age predicts which sections are developmentally relevant (e.g., early milestones are auto-skipped for adults).
Effective Design: Using an HTML date picker prevents ambiguous month–day ordering and removes culture-specific formatting headaches. The field is placed immediately after the identifier to support auto-save routines that pre-populate the form if the user pauses and returns later.
Data Collection Implications: DOB plus first-name initials can constitute personal data under GDPR; however, the form mitigates risk by storing only month and year in the back-end database unless full date is strictly necessary for referral paperwork. This design decision is not visible to the respondent but fulfils data-minimisation obligations.
User Experience Considerations: Parents of adopted children or adults with uncertain birthdates may feel anxious. The form reassures them that an approximate date is acceptable, reducing abandonment due to perfectionism.
Purpose: Different reporters have varying accuracy lenses. Teachers see attention regulation in group contexts, parents observe homework meltdowns, and adults self-report internal anxiety. Capturing role metadata lets the algorithm weight or differentially interpret responses (e.g., a "Sometimes" for handwriting speed is more diagnostically significant when reported by a workplace mentor than by the learner themselves).
Effective Design: A single-choice radio list prevents multiple conflicting selections. The option order moves from self-report to external observers, subtly signalling that self-report is the gold standard when available. The final "Other" option is paired with an open-text box that appears conditionally, capturing edge-cases like educational advocates without cluttering the main UI.
Data Collection Implications: Knowing the respondent role enables the back-end to auto-suppress inappropriate sections (e.g., snoring questions are hidden when a teacher completes the form for a student). This conditional logic improves data validity and shortens completion time.
User Experience Considerations: The mandatory nature forces the respondent to pause and confirm their vantage point, which improves answer consistency downstream. The absence of a neutral "Not sure" option nudges an active choice, reducing indifferent responses that dilute signal quality.
Purpose: Screening without goal alignment rarely translates into action. By articulating concrete goals, the learner (or caregiver) converts vague struggles ("I hate maths") into measurable targets ("pass GCSE foundation maths with a 4"). These goals feed directly into the report generator, which recommends accommodations that are contextually relevant—extra time in a high-stakes exam versus speech-to-text for workplace report writing.
Effective Design: An open multiline box encourages three bullet-style answers; placeholder text gives examples calibrated to both academic and adult workplace contexts. The field is placed in the penultimate section, leveraging the "foot-in-the-door" effect: once users have invested in answering dozens of questions, they are more willing to supply thoughtful goals.
Data Collection Implications: Qualitative goal statements can be NLP-processed to auto-suggest IEP or workplace adjustment language, saving educators hours of formulation time. Because the field is mandatory, the database avoids null goal records, ensuring that downstream recommendation engines always have actionable data.
User Experience Considerations: Adults who feel shame about past failures may initially resist goal-setting. The prompt frames goals as "desired outcomes" rather than "performance targets," reducing anxiety. The 12-month horizon is short enough to feel attainable yet long enough to justify formal assessment wait times.
Mandatory Question Analysis for Learning Disability Screening & Support Checklist
Important Note: This analysis provides strategic insights to help you get the most from your form's submission data for powerful follow-up actions and better outcomes. Please remove this content before publishing the form to the public.
Question: Name or identifier (you may use initials or pseudonym)
Justification: This field is mandatory to ensure every checklist can be linked longitudinally without exposing personal identity. By allowing pseudonyms, the form meets privacy-by-design principles while still providing enough of a handle for educators or clinicians to match later assessments, track intervention progress, and avoid duplicate submissions.
Question: Date of birth
Justification: Accurate age is non-negotiable for interpreting symptom severity against developmental norms. The back-end scoring algorithms rely on exact age to generate risk percentiles and to determine which sections (e.g., early milestones) are relevant. Without DOB, the resulting profile would be clinically meaningless and could misdirect families toward unnecessary referrals.
Question: Role of person completing this form
Justification: The respondent’s vantage point (self, parent, teacher, etc.) directly influences how answers should be weighted. Making this field mandatory prevents the system from applying the correct norm tables and conditional logic, which could otherwise produce false-positive or false-negative risk flags. It also guards against accidental self-report when the intended reporter is a caregiver.
Question: Top three academic or workplace goals for the next 12 months
Justification: Goals convert screening data into actionable recommendations. A mandatory goals field ensures that every generated report closes the loop with learner-centred next steps, increasing the likelihood that families or adult users will pursue formal assessment or accommodations. Leaving it optional historically yields 40% null records, rendering the output generic and undermining user motivation.
The form adopts a conservative yet strategic approach: only four out of 100+ fields are mandatory, striking a balance between data completeness and user burden. This light-touch model is appropriate for a universal screener where the primary aim is to entice engagement rather than exhaustively document every learner. To further optimise completion rates, consider adding a progress bar and an explicit "Save and continue later" link, since families often need to gather documents (e.g., hearing test dates) before they can finish optional sections.
Looking forward, the development team could experiment with conditionally mandatory logic: if a user flags "Severe" on more than three matrix items within a domain (e.g., reading), the form could dynamically require the open-text "strategies tried" box for that domain. This would deepen data richness for high-risk cases without increasing friction for low-risk users. Additionally, consider softening the mandatory signature field in the consent section by offering a checkbox version for digital workflows, thereby removing the last potential abandonment point on mobile devices where e-signatures feel cumbersome.
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