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

Never (0) Occasionally (1) Often (2) Very Often (3)

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

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 allow through when given directions and fails to finish activities (not due to refusal 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. Avoid, dislikes, or does not want to start task that require ongoing mental effort

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

8. Is easily distracted by noises or other stimuli

Never (0) Occasionally (1) Often (2) Very Often (3)

9. Is forget in daily activities

Never (0) Occasionally (1) Often (2) Very Often (3)

10. Fidgers with hands or feet or squirms in seat

Never (0) Occasionally (1) Often (2) Very Often (3)

11. Leaves seat when remaining seated is expected

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

13. Has difficulty playing or beginning quiet play activities

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 too much

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 his or her turn

Never (0) Occasionally (1) Often (2) Very Often (3)

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

Never (0) Occasionally (1) Often (2) Very Often (3)

Performance

19. Reading

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

20. Mathematics

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

21. Writing Expression

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

22. Relationship with peers

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

23. Following Direction

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

24. Disrupting Class

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

25. Assignment completion

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

26. Organizational skills

Excellent (1) Above Average (2) Average (3) Somewhat of a Problem (4) Problematic (5)

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, M.D. Revised - 0303

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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