NICHQ Vanderbilt Assessment Scale - Teacher Informant

Peds in a Pod Pediatrics, LLC

Teacher's Name

Class Name

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

Fails to give attention to details or makes careless mistakes in schoolwork

Never Occasionally Often Very Often

Has difficulty sustaining attention to tasks or activities

Never Occasionally Often Very Often

Does not seem to listen when spoken to directly

Never Occasionally Often Very Often

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

Never Occasionally Often Very Often

Has difficulty organizing tasks and activities

Never Occasionally Often Very Often

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

Never Occasionally Often Very Often

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

Never Occasionally Often Very Often

Is easily distracted by noises or other stimuli

Never Occasionally Often Very Often

Is forgetful in daily activities

Never Occasionally Often Very Often

Fidgets with hands or feet or squirms in seat

Never Occasionally Often Very Often

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

Never Occasionally Often Very Often

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

Never Occasionally Often Very Often

Has difficulty playing or engaging in leisure activities quietly

Never Occasionally Often Very Often

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

Never Occasionally Often Very Often

Talks excessively

Never Occasionally Often Very Often

Blurts out answers before questions have been completed

Never Occasionally Often Very Often

Has difficulty waiting in line

Never Occasionally Often Very Often

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

Never Occasionally Often Very Often

Loses temper

Never Occasionally Often Very Often

Actively defies or refuses to go along with adults' requests or rules

Never Occasionally Often Very Often

Is angry or resentful

Never Occasionally Often Very Often

Is spiteful and vindictive

Never Occasionally Often Very Often

Bullies, threatens, or intimidated others

Never Occasionally Often Very Often

Initiates physical fights

Never Occasionally Often Very Often

Lies to obtain goods for favors or to avoid obligations (eg, "cons" others)

Never Occasionally Often Very Often

Is physically cruel to people

Never Occasionally Often Very Often

Has stolen items of nontrivial value

Never Occasionally Often Very Often

Deliberately destroys others' property

Never Occasionally Often Very Often

Is fearful, anxious, or worried

Never Occasionally Often Very Often

Is self-conscious or easily embarrassed

Never Occasionally Often Very Often

Is afraid to try new things for fear of making mistakes

Never Occasionally Often Very Often

Feels worthless or inferior

Never Occasionally Often Very Often

Blames self for problems; feels guilty

Never Occasionally Often Very Often

Feels lonely, unwanted, or unloved; complains that "no one loves him or her"

Never Occasionally Often Very Often

Is sad, unhappy, or depressed

Never Occasionally Often Very Often

Performance

Reading

Excellent Above Average Average Somewhat of a Problem Problematic

Mathematics

Excellent Above Average Average Somewhat of a Problem Problematic

Written expression

Excellent Above Average Average Somewhat of a Problem Problematic

Classroom Behavioral Performance

Relationship with peers

Excellent Above Average Average Somewhat of a Problem Problematic

Following directions

Excellent Above Average Average Somewhat of a Problem Problematic

Disrupting class

Excellent Above Average Average Somewhat of a Problem Problematic

Assignment completion

Excellent Above Average Average Somewhat of a Problem Problematic

Organizational skills

Excellent Above Average Average Somewhat of a Problem Problematic

Comments

Please return this form to:

Mailing Address:

Fax Number:

For Office Use Only

Total number of questions scored 2 or 3 (often or very often) in questions 1-9:

Total number of questions scored 2 or 3 (often or very often) in questions 10-18:

Total Symptom Score for questions 1-18:

Total number of questions scored 2 or 3 (often or very often) in questions 19-28:

Total number of questions scored 2 or 3 (often or very often) in questions 29-45

Total number of questions scored 4 or 5 (somewhat of a problem or problematic) in questions 36-43:

Average performance score:

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