Vanderbilt Assessment Scale (Teacher - Informant)

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 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

Never [0] Occasionally [1] Often [2] Very Often [3]

2. Has difficulty sustaining attention to tasks or activities

Never [0] Occasionally [1] Often [2] Very Often [3]

3. Does not seem to listen when spoken to directly

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

5. Has difficulty organizing tasks and activities

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

8. Is easily distracted by extraneous stimuli

Never [0] Occasionally [1] Often [2] Very Often [3]

9. Is forgetful in daily activities

Never [0] Occasionally [1] Often [2] Very Often [3]

10. Fidgets with hands or feet or squirms in seat

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

13. Has difficulty playing or engaging in leisure activities quietly

Never [0] Occasionally [1] Often [2] Very Often [3]

14. Is “on the go” or often acts as if “driven by a motor”

Never [0] Occasionally [1] Often [2] Very Often [3]

15. Talks excessively

Never [0] Occasionally [1] Often [2] Very Often [3]

16. Blurts out answers before questions have been completed

Never [0] Occasionally [1] Often [2] Very Often [3]

17. Has difficulty waiting in line

Never [0] Occasionally [1] Often [2] Very Often [3]

18. Interrupts or intrudes on others (eg, butts into conversations/games)

Never [0] Occasionally [1] Often [2] Very Often [3]

19. Loses temper

Never [0] Occasionally [1] Often [2] Very Often [3]

20. Actively defies or refuses to comply with adult’s requests or rules

Never [0] Occasionally [1] Often [2] Very Often [3]

21. Is angry or resentful

Never [0] Occasionally [1] Often [2] Very Often [3]

22. Is spiteful and vindictive

Never [0] Occasionally [1] Often [2] Very Often [3]

23. Bullies, threatens, or intimidates others

Never [0] Occasionally [1] Often [2] Very Often [3]

24. Initiates physical fights

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

26. Is physically cruel to people

Never [0] Occasionally [1] Often [2] Very Often [3]

27. Has stolen items of nontrivial value

Never [0] Occasionally [1] Often [2] Very Often [3]

28. Deliberately destroys others’ property

Never [0] Occasionally [1] Often [2] Very Often [3]

29. Is fearful, anxious, or worried

Never [0] Occasionally [1] Often [2] Very Often [3]

30. Is self-conscious or easily embarrassed

Never [0] Occasionally [1] Often [2] Very Often [3]

31. Is afraid to try new things for fear of making mistakes

Never [0] Occasionally [1] Often [2] Very Often [3]

32. Feels worthless or inferior

Never [0] Occasionally [1] Often [2] Very Often [3]

33. Blames self for problems; feels guilty

Never [0] Occasionally [1] Often [2] Very Often [3]

34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”

Never [0] Occasionally [1] Often [2] Very Often [3]

35. Is sad, unhappy, or depressed

Never [0] Occasionally [1] Often [2] Very Often [3]

Performance

Academic Performance

Classroom Behavioral Performance

Please return this form to

Mailing address

Fax number

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Revised - 0303

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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 19-28

Total number of questions scored 2 or 3 in questions 19-28

Total number of questions scored 2 or 3 in questions 29-35

Total number of questions scored 4 or 5 in questions 36-43

Average Performance Score

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