Delta Screener

Today's date: ______________________________
Revised: May, 2003

Name____________________________
Birth date_______________
Age________

Year /month /day
Completed together with______________________________________


Post Secondary Academic Status

graphic of checkbox Full-time student graphic of checkbox Part-time student graphic of checkbox Special Studies

Program _________________________________
Semester/Level _____________________

1. How many courses are you taking this semester? __________________________________
Please list each of your courses below:

________________________________

________________________________


________________________________

________________________________

________________________________

________________________________


________________________________

________________________________


2. What difficulties are you having now?
_______________________________________________________________________________

_______________________________________________________________________________

3. Please indicate any of the following problems currently affecting your learning:
graphic of checkbox attendance
graphic of checkbox note taking
graphic of checkbox disorganization
graphic of checkbox time management
graphic of checkbox study skills
graphic of checkbox anxiety:
test ___, speaking ___, performance ___
graphic of checkbox test taking
graphic of checkbox not handing in assignments
graphic of checkbox procrastination
graphic of checkbox over-extended with work/activities
graphic of checkbox memory problems