Form Wtw 18 - Learning Needs Screening Page 3
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
LEARNING NEEDS SCREENING
CLIENT NAME
COUNTY CASE NUMBER
INTERVIEWER NAME
INTERVIEW DATE
INTERVIEWER TITLE
SECTION I
YES
NO
I
I
1. Have you had any problems learning in middle school or junior high? . . . . . . . . . . . . . . . . . .
I
I
2. Do you have difficulty working from a test booklet to an answer sheet? . . . . . . . . . . . . . . . . .
I
I
3. Do you have difficulty or experience problems working with numbers in a column? . . . . . . . .
I
I
4. Do you have trouble judging distances? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I
I
5. Do any family members have learning problems? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Count the number of “YES” answers for Section I ______ X 1 = ______ Subtotal for Section I
SECTION II
YES
NO
I
I
6. Have you had any problems learning in elementary school? . . . . . . . . . . . . . . . . . . . . . . . . . .
I
I
7. Do you have difficulty or experience problems mixing mathematical signs (+/x)? . . . . . . . . . .
Count the number of “YES” answers for Section II ______ X 2 = ______ Subtotal for Section II
SECTION III
YES
NO
I
I
8. Do you have difficulty or experience problems filling out forms? . . . . . . . . . . . . . . . . . . . . . . .
I
I
9. Do you experience difficulty memorizing numbers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I
I
10. Do you have difficulty remembering how to spell simple words you know? . . . . . . . . . . . . . . .
Count the number of “YES” answers for Section III ______ X 3 = ______ Subtotal for Section III
SECTION IV
YES
NO
I
I
11. Do you have difficulty or experience problems taking notes?. . . . . . . . . . . . . . . . . . . . . . . . . .
I
I
12. Do you have trouble adding or subtracting small numbers in your head? . . . . . . . . . . . . . . . .
I
I
13. Were you ever in a special program or given extra help in school? . . . . . . . . . . . . . . . . . . . . .
Count the number of “YES” answers for Section IV ______ X 4 = ______ Subtotal for Section IV
0
TOTAL of Sections I through IV: ________________
If total is 12 or more, refer for further evaluation. Complete the next page regardless of the score.
PAGE 3 OF 4
WTW 18 (4/16) REQUIRED FORM - NO SUBSTITUTES PERMITTED
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