D4 NICHQVanderbilt Assessment Scale-TEACHER Informant

Teacher's Na me: _ Class Ti me: _ Class Na me/Period: _

Today 's Date: _ Chi ld's Name: Gra de Level: _

Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child's behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors: _

Is this evaluation based on a time when the child 0 was on medication D was not on medication D not sure?

Symptoms Never Occasionally Often Very Often

1. Fa ils ~o g~e atte n tion to deta ils or makes ca reless mis ta kes in schoolwork 0 1 2 3

,_ 2. Has di fficul ty~ us t a i n i n g a tte n tio n to tasks or ac tivities 0 I 2 3

3. Do e~o t seem ~ listen when s pol~n to_di rec0Y, , 0 1 ---­

2 3

4. Does not follow through on inst ructions an d fails to fin ish sch oolwork 0 1 2 3 ,. . ~o.!: du e to opposi tional behavio r or failure to unders_ta nd)

5. Has difficult y~ga ni z in g t ~k~ a ~acti v it i e s 0 2 3

6. Avoids, di slikes, or is reluc tan t to engage in tasks tha t req u ire su st ained 0 2 3 mental effor t

7. Loses things necessa ry for tasks or activi ties (school assignmen ts, 0 2 3 pencils, or boo ks )

8. Is easilr..d ist racted by extraneous st im uli 0 2 3

9. Is fo rge tfu l in da ily activi ties ._ - ---­- - - - - - - - - - - - - 0- - - - - - - - - - 2 - 3 -­-­- -10. Fidge ts with ha,nds or feet or squirm s in sea t 0 2 3

11. Leaves sea t in classroom or in other situa tions in which remaining 0 2 3 sea ted is expected

----­ - --­12. Runs abo ut or climbs excessively in si tuations in which remaining 0 2 3

sea ted is expected

13. Has~i ffi c~ l t y playin g 0 .1' engaging in leisu re activi ties qu ietl y _ 0 1 2 3

14. Js-,:on the go" or often a c~s as if "d r iven by a motor" 0 1 ' ­

2 -

3

IS. Talks excess ively -­ -­ --­

0 1 2 3 -----­

16. Bl u rt ~ o ut~ nswe rs .? e fo r~qu e s t i o n s h ave been complet~ __ . 0 -

1 -­ 2 3

~7: Has di fficulty wa iting_in line 0 1 2 3

18. In terru pts or in trudes o n others (eg, butts into co nversa tions/ games) 0 1 2 -

3

.2?.:... Loses tem per 0 1 2 3

20. Actively defies or refuses to comply with adu lt's requests or rules 0 1 2 3

21. Is ang:::y or resentfu l 0 1 2 3

22, Is spi teful and vind ictive 0 I 2 3

23 . Bull ies, th reatens, or inti m ida tes o thers 0 1 2 3

24. In it iat es physical figh ts 0 1 2 3

25. Lies to ()b_tai,n ,goods fo r favors or to avo id obliga tions (eg, "cons" others) 0 1 2 3

~. Is physically cruel to pe~p l e 0 1 2 3 -

27. Has stolen items of non trivial value -­ --­ 0 1 2 3

.

-.28. De liberat ely .~ e ~ t l:o y S ~t~~rs.:.E.r~_e r t y 0 1 --­ -

2 3

29. Is fearful , anxious, o r wo rri ed - - -­

0 1 2 -­

3

~ Is s elf-co~scious or easi ly em barrassed 0 1 2 3 --­

31. Is afra id to tr y new things for fear of maki ng m istakes 0 1 2 3

T he recommendations in thi:> p ub licatio n d o not indicarc un exclu sive course of treatment Copyright '1''j2002 Ame r ica n Acad emy or Pcdi.uri cs and Nationa l luit iat ivc for Ch ild ren's o r serve as a standard of medical care, variatio ns. taking into account individual cu'cum­ Healthcarc Quality stances, mar be ap p ro p riat e. Adapted fro m the Vanderb ilt Rating Scale s devel op ed b)' Mark L. w ol raich. MD .

RCVIOcd ' 0303

American Academy of Pediatrics NICHQ DED ICATED TO THE H EALT H OF Al.l. CH IL DR EN' Nauonel Initiat ive Ior Children's He althcare Oualuv

HE03S1

- -

D4 NICHQVanderbilt Assessment Scale-TEACHER Informant, continued

Teacher's Name: Class Ti me: Class Name/Period: _

Today's Date: Child's Na me: Gra de Level: _

Symptoms (continued) Never Occasionally Often Very Often

32. Feels worthless or inferior ---- ­ -

~. Blames self for problems; feels gu_il_ty'- ­- -

_

o - ­ - ­

o -

2

2

1 - -- ­ - ­

1 -­ 3

--- ­3

34. Feels lo n~y~nwan t ~d, ~ unloved; complains that "no one loves_him or ~er" o 1 - 2 -----­

3

35. Is sad , unhappy, or depressed o 1 2 3

Somewhat Performance Above ofa Academic Performance Excellent Average Average Problem Problematic

~Rea d i n g 2 3 4 5

37. Ma thematics 2 3 4 5

38. Wri tten expression 2 3 4 5

Somewhat Above of a

Classroom Behavioral Performance Excellent Average Average Problem Problematic

~~ Relationship with peers 2 3 4 5

40 . Following directions 2 3 4 5

41. Disrupting class 2 3 4 5

42. Assignmen t completion 2 3 4 5

43. O rgan izational skills 2 3 4

Comments:

Please return thi s form to:

Mailing address : _

Fax number:

For Office Use Only

Total number of questions sco red 2 or 3 in questions 1- 9:

Total n umber of que stions scored 2 or 3 in que st ions 10-18: _

Tota l Sym pto m Score for qu esti on s 1-18:

Total numbe r of ques tion s scored 2 or 3 in que st ions 19- 28: _

Total number of que stions score d 2 or 3 in questions 29- 35: _

Tota l number of questions scored 4 or 5 in que stions 36-43: _

Average Performance Scor e:

American Academy of Pediatrics NICHQ

Nau onet Initi ative (or Chi ldren 'sHealthc ere O UaJiTYDEDI C AT ED TO TH E HEA LTH or ALL C H I LDR EN ­

11-20/1<,'0303

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