Dysgraphia Teacher Input Form — Elementary

Student Characteristics Checklist for Dysgraphia Assessment

Student Information

Student Name

Grade

Campus

Teacher Name

Date Form Completed

Currently Receiving Services

N/A 504 Plan IEP RtI / MTSS

Handwriting Characteristics Checklist

For each characteristic, check the concern column if observed. Notes column is optional.

Characteristic of Concern	Observed?	Notes / Specifics
Memory
Misses letters / numbers
Unidentifiable letter forms / mixes capitals and lowercase
Orientation
Reverses letters (specify)
Placement
Misplaces letters / poor baseline placement
Doesn't ascend or descend letters correctly
Size
Too big for grade level / varies significantly
Too small to read easily
Sequence
Makes strokes out of order
Forms letters in a non-standard way
Spacing
Too much space / irregular spacing
Runs words together
Control
Misshapen letters / numbers
Letters look squiggly or shaky
Self-Correction
Erases too much / write-overs / cross-outs
Works carelessly / rushes

Additional Characteristics — Check each observed:

Variably shaped / poorly formed letters Difficulty copying words accurately Improper letter slant Overuse of short / familiar words Student difficulty reading own writing Low volume of written output Slow or labored written work Awkward, inconsistent, or poor pencil grip Lack of endurance when writing Light or hard pressure / reports hand fatigue Slow writing and/or copying Avoidance of written tasks

Teacher Comments — Handwriting Characteristics

Written Composition & Spelling Observations

Written Composition Observations

Highest Independent Writing Level

Single sentence Multi-paragraph essay Single paragraph Consistent with grade expectations

Drafting

Illegible handwriting due to poor mechanics (e.g., size, spacing, letter formation) Student's quality of writing decreases with the length of the task Student's pace of writing is not sufficient to keep up with his/her thoughts Student has frequent mistakes in sentence structure and/or grammatical errors

Revising & Editing

Student lacks attention to detail / misses obvious mistakes Student can 'hear' mistakes (word omissions, sentence structure) when read aloud Student can independently correct punctuation/capitalization when prompted Student can correct most spelling errors using dictionary, word bank, or spell checker

Teacher Comments — Written Composition

Spelling Observations

Errors spelling simple / frequent words Frequent errors for grade level Over-reliance on phonetic spelling Inability to recall accurate spelling patterns Difficulty spelling words in isolation Difficulty spelling words in context Consistent with TEKS expectations

Teacher Comments — Spelling

Elementary Written Task Demands

Task	Success Independently?	Success with Accommodations?
Copying Tasks
Copy from the board	Y N	Y N
Copy from a source at desk	Y N	Y N
Copy equations or complete calculations	Y N	Y N
Dictation Tasks
Spelling test	Y N	Y N
Take notes during lecture	Y N	Y N
Composition Tasks
Multiple choice questions	Y N	Y N
Fill in the blank	Y N	Y N
Short answer	Y N	Y N
Compose single paragraph	Y N	Y N
Compose multi-paragraph compositions	Y N	Y N

Teacher Comments — Task Demands