Vanderbilt initial assessment - Teacher

NICHQ VANDERBILT ASSESSMENT SCALE - Teacher informant

* Indicates required field

Teacher's Name *

Class Time *

Class Name/Period *

Today's date *

Child's Name *

Grade 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 schoold 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 *

was on medication was not on medication not sure?

Please indicate the number of weeks or months you have been able to evaluate the behaviors: *

Please choose accordingly to the following symptoms: (0=Never; 3=Very Often)

Fails to give attention to details or makes careless mistakes in schoolwork *

Has difficulty sustaining attention to tasks or activities *

Does not seem to listen when spoken directly *

Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand) *

Has difficulty organizing tasks and activities *

Avoids, dislikes, or does not want to start tasks that require ongoing mental effort *

Loses things necessary for tasks or activities (toys, assignments, pencils, or books) *

Is easily distracted by noises or other stimuli *

Is forgetful in daily activities *

Fidgets with hands or feet or squirms in seat *

Leaves seat in classroom or in other sisutations in which remaining seated is expected *

Runs about or climbs excessively in situations in which remaining seated is expected *

Has difficulty playing or engagin in leisure activities quietly *

Is "on the go" or often acts as if "driven by a motor" *

Talks excessively *

Blurts out answers before questions have been completed *

Has difficulty waiting in line *

Interrupts or intrudes on others (eg: butts into conversations/games) *

Loses temper *

Actively defies or refuses to go along with adults' requests or rules *

Is angry or resentful *

Is spiteful and vindictive *

Bullies, threatens, or intimidates others *

Initiate physical fights *

Lies to get out of trouble or to avoid obligations (ie: "cons" others) *

Is physically cruel to people *

Has stolen items of nontrivial value *

Deliberately destroys others' proprety *

Is fearful, anxious, or worried *

Is self-conscious or easily embarrassed *

Is afraid to try new things for fear of making mistakes *

Feels worthless or inferior *

Blames self for problems, feels guilty *

Feels lonely, unwanted, or unloved; complains that "no one loves him or her" *

Is sad, unhappy, or depressed *

Please choose accordingly to the following academic perfomances: (1=Excellent; 5=Problematic)

Reading *

Mathematics *

Written expression *

Please choose accordingly to the following classroom behavioral performances: (1=Excellent; 5=Problematic)

Relationship with peers *

Following directions *

Disrupting class *

Assignment completion *

Organizational skills *

Comments *

For Office Use Only

Total number of questions scored 2 or 3 in questions 1-9 *

Total number of questions scored 2 or 3 in questions 10-18 *

Total Symptom Score for questions 1-18 *

Total number of questions scored 2 or 3 in questions 19-26 *

Total number of questions scored 2 or 3 in questions 27-40 *

Total number of questions scored 2 or 3 in questions 41-47 *

Total number of questions scored 2 or 3 in questions 48-55 *

Average Performance Score *

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NICHQ VANDERBILT ASSESSMENT SCALE - Teacher informant

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