NICHQ Vanderbilt Assessment Follow-up - TEACHER Informant
Teacher's Name
Class Time
Class Name/Period
Today's Date
Child's Full 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 behaviour since the last assessment scale was filled out. Please indicate the number of weeks or months you have been able to evaluate the behaviours:
Is this evaluation based on a time when the child
*
was on medication
was not on medication
not sure?
Symptoms
*
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Fails to give attention to details or makes careless mistakes in schoolwork
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Has difficulty sustaining attention to tasks or activities
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Does not seem to listen when spoken to directly
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Does not follow through when given directions and fails to finish schoolwork (not due to oppositional behaviour or failure to understand)
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Has difficulty organising tasks and activities
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Loses things necessary for tasks or activities (school assignments, pencils, or books)
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Is easily distracted by extraneous stimuli
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Is forgetful in daily activities
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Fidgets with hands or feet or squirms in seat
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Leaves seat in classroom or in other situations in which remaining seated is expected
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Runs about or climbs excessively in situations in which remaining seated is expected
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Has difficulty playing or engaging in leisure activities quietly
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Is "on the go" or often acts as if "driven by a motor"
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Talks excessively
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Blurts out answers before questions have been completed
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Has difficulty waiting in line
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Interrupts of intrudes on others' (e.g., butts into conversations/games)
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
Performance
*
Excellent (1)
Above Average (2)
Average (3)
Somewhat of a Problem (4)
Problematic (5)
Reading
Excellent (1)
Above Average (2)
Average (3)
Somewhat of a Problem (4)
Problematic (5)
Mathematics
Excellent (1)
Above Average (2)
Average (3)
Somewhat of a Problem (4)
Problematic (5)
Written expression
Excellent (1)
Above Average (2)
Average (3)
Somewhat of a Problem (4)
Problematic (5)
Relationship with peers
Excellent (1)
Above Average (2)
Average (3)
Somewhat of a Problem (4)
Problematic (5)
Following direction
Excellent (1)
Above Average (2)
Average (3)
Somewhat of a Problem (4)
Problematic (5)
Disrupting class
Excellent (1)
Above Average (2)
Average (3)
Somewhat of a Problem (4)
Problematic (5)
Assigment completion
Excellent (1)
Above Average (2)
Average (3)
Somewhat of a Problem (4)
Problematic (5)
Organisational skills
Excellent (1)
Above Average (2)
Average (3)
Somewhat of a Problem (4)
Problematic (5)
Side Effects: Has thechild experienced any of the following side effects or problems in the past week?
*
None
Mild
Moderate
Severe
Headache
None
Mild
Moderate
Severe
Stomachache
None
Mild
Moderate
Severe
Change of appetite - explain below
None
Mild
Moderate
Severe
Trouble sleeping
None
Mild
Moderate
Severe
Irritability in the late morning, late afternoon, or evening - explain below
None
Mild
Moderate
Severe
Socially withdrawn - decreased interaction with others
None
Mild
Moderate
Severe
Extreme sadness or unusual crying
None
Mild
Moderate
Severe
Dull, tired, listless behaviour
None
Mild
Moderate
Severe
Tremors/feeling shaky
None
Mild
Moderate
Severe
Repetitive movements, tics, jerking, twitching, eye blinking - explain below
None
Mild
Moderate
Severe
Picking at skin or fingers, nail biting, lip or cheek chewing - explain below
None
Mild
Moderate
Severe
Sees or hears things that aren't here
None
Mild
Moderate
Severe
Explain/Comments
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