NICHQ Vanderbilt Assessment Follow-up—TEACHER Informant

REIS 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 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 not 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 follow 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. Avoids, dislikes, or does not want to start tasks 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 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 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 others’ 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. Written 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

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

Headache

None Milld Moderate Severe

Stomachache

None Milld Moderate Severe

Change of appetite—explain below

None Milld Moderate Severe

Trouble sleeping

None Milld Moderate Severe

Irritability in the late morning, late afternoon, or evening—explain below

None Milld Moderate Severe

Socially withdrawn—decreased interaction with others

None Milld Moderate Severe

Extreme sadness or unusual crying

None Milld Moderate Severe

Dull, tired, listless behavior

None Milld Moderate Severe

Tremors/feeling shaky

None Milld Moderate Severe

Repetitive movements, tics, jerking, twitching, eye blinking—explain below

None Milld Moderate Severe

Picking at skin or fingers, nail biting, lip or cheek chewing—explain below

None Milld Moderate Severe

Sees or hears things that aren’t there

None Milld Moderate Severe

Explain/Comments:

For Office Use Only

Total Symptom Score for questions 1–18:

Average Performance Score:

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