NICHQ Vanderbilt Assessment Scale – TEACHER Informantion

Today's Date:

Student's Name

Teacher's Name:

Class Time: *

Hours

Minutes

Class Name/Period *

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 this
behavior:

Is this evaluation based on when the child *

Symptoms

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 to directly *

Does not follow through on instructions and fails to finish schoolwork(not due to oppositional behavior or failure to understand) *

Has difficulty organizing tasks and activities *

Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort *

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

Is easily distracted by extraneous stimuli *

Is forgetful in daily activities *

Fidgets with hands or feet or squirms in seat *

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

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

Has difficulty playing or engaging 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 comply with adult’s requests or rules *

Is angry or resentful *

Is spiteful and vindictive *

Bullies, threatens, or intimidates others *

Initiates physical fights *

Lies to obtain goods for favors or to avoid obligations (eg, “cons” others) *

Is physically cruel to people *

Has stolen items of nontrivial value *

Deliberately destroys others’ property *

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 *

Performance

Reading *

Mathematics *

Written expression *

Classroom Behavioral Performance

Relationship with peers *

Following directions *

Disrupting class *

Assignment completion *

Organizational skills *

All question are compulsory. Answer all question correctly and input how many 0's 1's 2's 3's in your answers inside this text box

SignatureTyping you name here represents your signature

Date

Month

Day

Year

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

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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 theschool year

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