NICHQ Vanderbilt Assessment Scale – TEACHER Informant Page

NICHQ Vanderbilt Assessment Scale - TEACHER Informant

Teacher's Name:*
First Last
Class Time:*
Class Name/Period:*
Today's Date:*
MM slash DD slash YYYY
Child's Name:*
First Last
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 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:*
- was on medication
- was not on medication
- not sure?
Symptoms
1. Fails to give attention to details or makes careless mistakes in schoolwork.*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
2. Has difficulty sustaining attention to tasks or activities.*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
3. Does not seem to listen when spoken to directly.*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand)*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
5. Has difficulty organizing tasks and activities*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
8. Is easily distracted by extraneous stimuli*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
9. Is forgetful in daily activities.*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
10. Fidgets with hands or feet or squirms in seat.*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
11. Leaves seat in classroom or in other situations in which remaining seated is expected*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
12. Runs about or climbs excessively in situations in which remaining seated is expected*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
13. Has difficulty playing or engaging in leisure activities quietly*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
14. Is “on the go” or often acts as if “driven by a motor”.*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
15. Talks excessively*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
16. Blurts out answers before questions have been completed.*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
17. Has difficulty waiting in line*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
18. Interrupts or intrudes on others (eg, butts into conversations/games)*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
19. Loses temper*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
20. Actively defies or refuses to go along with adults’ requests or rules*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
21. Is angry or resentful*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
22. Is spiteful and vindictive*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
23. Bullies, threatens, or intimidates others*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
24. Initiates physical fights*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others)*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
26. Is physically cruel to people*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
27. Has stolen items of nontrivial value*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
28. Deliberately destroys others’ property*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
29. Is fearful, anxious, or worried*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
30. Is self-conscious or easily embarrassed*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
31. Is afraid to try new things for fear of making mistakes*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
32. Feels worthless or inferior*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
33. Blames self for problems; feels guilty*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
35. Is sad, unhappy, or depressed*
- 0 - Never
- 1 - Occasionally
- 2 - Often
- 3 - Very Often
Academic Performance
36. Reading*
- 1 - Excellent
- 2 - Above Average
- 3 - Average
- 4 - Somewhat of a Problem
- 5 - Problematic
37. Mathematics*
- 1 - Excellent
- 2 - Above Average
- 3 - Average
- 4 - Somewhat of a Problem
- 5 - Problematic
38. Written expression*
- 1 - Excellent
- 2 - Above Average
- 3 - Average
- 4 - Somewhat of a Problem
- 5 - Problematic
Classroom Behavioral Performance
39. Relationship with peers*
- 1 - Excellent
- 2 - Above Average
- 3 - Average
- 4 - Somewhat of a Problem
- 5 - Problematic
40. Following directions*
- 1 - Excellent
- 2 - Above Average
- 3 - Average
- 4 - Somewhat of a Problem
- 5 - Problematic
41. Disrupting class*
- 1 - Excellent
- 2 - Above Average
- 3 - Average
- 4 - Somewhat of a Problem
- 5 - Problematic
42. Assignment completion*
- 1 - Excellent
- 2 - Above Average
- 3 - Average
- 4 - Somewhat of a Problem
- 5 - Problematic
43. Organizational skills*
- 1 - Excellent
- 2 - Above Average
- 3 - Average
- 4 - Somewhat of a Problem
- 5 - Problematic
Comments:

NICHQ Vanderbilt Assessment Scale - TEACHER Informant

Symptoms

Academic Performance

Classroom Behavioral Performance