DIAL- 3 SAMPLE FORM
Carol Mardell-Czudnowski
Dorothea S. Goldenberg
Child's Name: _________________________
Nickname: _________________________ Boy ☐ Girl ☐
Address: _________________________
Phone Number: _________________________ Child's Primary Language:
_________________________
Mother's Name: _________________________
Father's Name: _________________________
Coordinator's Name: _________________________ Screening Date: ____ /____
/____
School: _________________________ Birth Date: ____ /____ /____
Teacher/Class: _________________________ Chronological Age: ____ years ____
months ____ days
Score Summary
| Area | Scaled Score | % Total | Other | Potential Delay |
|-----------------|------------------|-----------|--------|--------------------|
| Motor | | | |
|
| Concepts | | | |
|
| Language | | | |
|
| DIAL-3 Total | | | |
|
| Self-Help Development | | | | |
| Social Development | | | | |
Overall Screening Decision: _________________________
Behavioral Observations Total (max. = 54): _________________________
Refer for further social/affective assessment? No ☐ Yes ☐
Intelligibility Rating: _________________________
Refer for further speech/language assessment? No ☐ Yes ☐ (Ratings of poor
may warrant further investigation.)
Vision and Hearing Results
Refer for follow-up vision assessment? Vision + ☐ - ☐ No ☐ Yes ☐
Refer for follow-up hearing assessment? Hearing + ☐ - ☐ No ☐ Yes ☐
Comments: _________________________
Language Assessment
| Category | Ages 3-4 | Ages 5-6 | Scaled Score | Item Scaled Scores
|
| :---------------------- | :------- | :------- | :----------- | :----------------- |
| | 0 (Under 3 yrs) | 0-1 | | |
| | 0-1 | 0-1 | | |
| 1. Personal Data | | | | |
| A. First name/Age/Birthday | 0-1 | 0-1 | | |
| B. Last name/Boy-Girl/Birthday | 2-3 |2 | | |
| | 3-4 |3 | | |
| | 4-5 |4 | | |
| | |5 | | |
| 2. Articulation | 0-9 | | | |
| | | | | |
| cup/cheese/fish/thumb | 10-22 | | | |
| ring/leaf/truck/glove | 23-24 | | | |
| toast/zebra/dress/jar | 25-26 | | | |
| spoon |- | | | |
| 3. Objects & Actions | 0-6 | 0-4 | | |
| Objects | 7-9 | 5-9 | | |
| Actions | 10-11 | 10-11 | | |
| plane/fly it | 12-13 | 12 | | |
| car/drive it | 14 | 13 | | |
| clock/tell time | | 14 | | |
| pencil/write | | | | |
| hanger/hang clothes | | | | |
| whistle/make whistling noise | | | | |
| thermometer/tell how hot/cold | | | | |
| 4. Letters & Sounds |0 |0 | | |
| Ages 3 & 4 | 1-3 | 1-4 | | |
| Ages 5 & 6 | 4-5 | 5-9 | | |
| A. Alphabet Song | 6-10 | 10-14 | | |
| 0 = a-f, 1 = g-o, 2 = p-y, 3 = z | - | 15-17 | | |
| B. Letter Naming | | | | |
|SBKFGRW | | | | |
| C. Letter-Sound Correspondence | | | | |
|SBKfGrW | | | | |
| 5. Rhyming & "I Spy" |0 | | | |
| A. Rhyming: cat/bake/wag/ring/kite | 1-3 | | | |
| B. I Spy: /d/, /b/, /sh/, /ch/, /p/ | 4-8 | | | |
| 6. Problem Solving | 9-10 | | | |
| 1. Thirsty |- | | | |
| 2. Dark Room |0 | | | |
| 3. Break Something | 1-2 | | | |
| |3 | | | |
| |4 | | | |
| | 5-6 | | | |
| Scaled Score Total (max. 27) | | | | |
Behavioral Observations (For each behavior, circle the option that applies
to the child)
1. Separation from adult 4. Persistence (nonverbal) 7. Participation
* easy * stays with task * willingly participates
* hesitant * attempts task * needs encouragement
* unable to separate * refuses task * unwilling to try tasks
2. Crying/Whining 5. Attention 8. Impulsivity
* none * pays attention * waits for directions
* a little throughout task * begins before directions are
finished on some tasks
* a lot * pays attention some of * begins before directions
are finished on most tasks
the time
3. Verbal response to questions 6. Activity level 9. Understanding of
directions
* willing * pays attention only briefly * easily understands
