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Learning Needs Screening Tool |
Interview Date |
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BACKGROUND INFORMATION |
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NAME |
BIRTH DATE |
INTERVIEWER NAME |
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SEX
Male Female |
HOUSEHOLD TYPE
Single
parent Two parents |
COMMUNITY SERVICES OFFICE (CSO) |
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JAS NUMBER |
ETHNICITY
African
American Asian Caucasian Hispanic/Latino Native American |
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ACES NUMBER |
COMPLETED YEARS OF FORMAL EDUCATION |
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DEGREE (S) ATTAINED
High School
Diploma GED Technical/vocational AA degree Other (specify): |
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WHAT KIND OF JOB WOULD YOU LIKE TO GET? |
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DO YOU HAVE EXPEREINCE IN THIS FIELD OR A RELATED FIELD? |
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WHAT MAKES IT HARD FOR YOU TO GET OR KEEP THIS KIND OF
JOB? |
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WHAT WOULD HELP? |
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BEFORE ANSWERING THE
FOLLOWING QUESTIONS, READ THE STATEMENT ALOUD ON THE BACK TO THE CLIENT
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SEE INSTRUCTIONS ON BACK OF THIS PAGE |
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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? |
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1 x ______ = ______ = Count the
number of “YES’S.” Multiply by 1. |
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Section IIq 6.
Have you had any problems learning in elementary school? q 7.
Do you have difficulty or experience problems mixing mathematical
sighs (+/x)? |
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2 x _______ = _______ = Count the number of “YES’S.” Multiply by 2. |
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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? |
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3 x ______ = ______ = Count the number of “YES’S.”
Multiply by 3. |
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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? |
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4 x ______ = ______ = Count the
number of “YES’S.” Multiply by 4. |
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_______ Total:
If 12 or more, refer for further assessment. |
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LEARNING NEEDS SCREENING TOOL
BEFORE ASKING THE FOLLOWING QUESTIONS, READ THIS STATEMENT
ALOUD TO THE CLIENT:
“The following questions are about your school and life
experiences. This information will provide
a better understanding of the services you will need to be successfully
employed. We’re trying to find out how
it was for you (or your family members) back in school or how some of these
issues might affect your life now.
These questions will help us identify resources that will aid you in
self sufficiency planning with your caseworker.
Ask All questions.
1.
Ask the client each question in Sections I, II, III, and IV.
2.
Check YES if client answers the question with “yes”
3.
In each section, count the number of “yes” answers.
4.
Multiply the number of “yes” responses in each section by
the number shown in the “Count the number of YES’S” area. For example, multiply the number of Section
III “yes,’s” by 3.
5.
Record that product after the =sign in that area.
6.
Add up the numbers after the =sigh and enter that total in
the Total row.
7.
If the Total is 12 or more, the participant may need
further assessment and/or referral for employment related accommodation.