NICHQ Vanderbilt Assessment Scale - Teacher Informant

Northwest Suburban Pediatrics

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

2. Has difficulty sustaining attention to tasks or activities

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

3. Does not seem to listen when spoken to directly

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

5. Has difficulty organizing tasks and activities

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

8. Is easily distracted by extraneous stimuli

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

9. Is forgetful in daily activities

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

10. Fidgets with hands or feet or squirms in seat

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

13. Has difficulty playing or engaging in leisure activities quietly

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

15. Talks excessively

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

16. Blurts out answers before questions have been completed

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

17. Has difficulty waiting in line

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

19. Loses temper

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

21. Is angry or resentful

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

22. Is spiteful and vindictive

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

23. Bullies, threatens, or intimidates others

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

24. Initiates physical fights

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

26. Is physically cruel to people

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

27. Has stolen items of nontrivial value

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

28. Deliberately destroys others' property

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

29. Is fearful, anxious, or worried

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

30. Is self-conscious or easily embarrassed

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

32. Feels worthless or inferior

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

33. Blames self for problems: feels guilty

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

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

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

35. Is sad, unhappy, or depressed

1 - Never 2 - Occasionally 3 - Often 4 - Very Often

Performance

Academic Performance

36. Reading

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

37. Mathematics

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

38. Written expression

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

Classroom Behavioral Performance

39. Relationship with peers

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

40. Following directions

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

41. Disrupting class

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

42. Assignment completion

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

43. Organizational skills

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

Comments:

Please return this form to: NORTHWEST SUBURBAN PEDIATRICS

Mailing address: A. BOND MD., - R. STEIN MD.
455 S. ROSELLE RD. SUITE 209
SCHAUMBURG, IL 60193

Fax number: PH: 847 352-9910 - FAX: 847 352-4471

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 29-35:

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

Average Performance Score:

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