NICHQ Vanderbilt Assessment Follow-Up(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 your child you are rating and should reflect that child's behavior since the last assessment scale was filled out. 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 no on medication

not sure?

Symptoms

1. Does not pay attention to details or makes careless mistakes with, for example, homework

2. Has difficulty keeping attention to what needs to be done

3. Does not seem to listen when spoken to directly

4. Does not allow through when given directions and fails to finish activities (not due to refusal or failure to understand)

5. Has difficulty organizing tasks and activities

6. Avoid, dislikes, or does not want to start task that require ongoing mental effort

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

8. Is easily distracted by noises or other stimuli

9. Is forget in daily activities

10. Fidgers with hands or feet or squirms in seat

11. Leaves seat when remaining seated is expected

12. Runs about or climbs too much when remaining seated is expected

13. Has difficulty playing or beginning quiet play activities

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

15. Talks too much

16. Blurts out answers before questions have been completed

17. Has difficulty waiting his or her turn

18. Interrupts or intrudes in on other's conversations and/or activities

Performance

19. Reading

20. Mathematics

21. Writing Expression

22. Relationship with peers

23. Following Direction

24. Disrupting Class

25. Assignment completion

26. Organizational skills

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.

Side Effects: Has your child experienced any of the following side effects or problems in the past week?

1. Headache

2. Stomachache

3. Change of appetite (Explain Below)

Explaination:

4. Trouble sleeping

5. Irritability in the late morning, late afternoon, or evening (Explain Below)

Explaination:

6. Socially withdrawn - Decreased interaction with others

7. Extreme sadness or unusual crying

8. Dull, tired, listless behavior

9. Tremors/feeling shaky

10. Repetitive movements, tics, jerking, twitching, eye blinking (Explain below)

Explaination:

11. Picking at skin or fingers, nail biting, lip or cheek chewing (Explain below)

Explaination:

12. Sees or hears things that aren't there

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