Teacher ADHD Vanderbilt Assessment Form
Complete this teacher informant form based on the student’s classroom behavior over the past 6 months (up to two teachers from different class periods may be asked).
Patient and Teacher Information
Instructions
Patient First Name
*
Patient Last Name
*
Patient Date of Birth
-
Month
-
Day
Year
Date
Respondent Full Name
*
First Name
Last Name
Subject/Class Taught
*
Today’s Date
-
Month
-
Day
Year
Date
Vanderbilt Teacher Symptom Ratings
Fails to give close attention to details or makes careless mistakes in schoolwork
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Has difficulty sustaining attention to tasks or activities
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Does not seem to listen when spoken to directly
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Does not follow through on instructions and fails to finish schoolwork
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Has difficulty organizing tasks and activities
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Loses things necessary for tasks or activities
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Is easily distracted by extraneous stimuli
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Is forgetful in daily activities
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Fidgets with hands or feet or squirms in seat
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Leaves seat in classroom or in other situations when remaining seated is expected
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Runs about or climbs excessively in situations where it is inappropriate
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Has difficulty playing or engaging in leisure activities quietly
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Is 'on the go' or often acts as if 'driven by a motor'
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Talks excessively
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Blurts out answers before questions have been completed
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Has difficulty awaiting turn
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Interrupts or intrudes on others
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Often loses temper, argues with adults, or actively defies or refuses adult requests
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Performance Ratings
Reading
*
Excellent
1
2
3
4
Problematic
5
1 is Excellent, 5 is Problematic
Math
*
Excellent
1
2
3
4
Problematic
5
1 is Excellent, 5 is Problematic
Written Expression
*
Excellent
1
2
3
4
Problematic
5
1 is Excellent, 5 is Problematic
Assignment Completion
*
Excellent
1
2
3
4
Problematic
5
1 is Excellent, 5 is Problematic
Classroom Disruption
*
Excellent
1
2
3
4
Problematic
5
1 is Excellent, 5 is Problematic
Following Directions
*
Excellent
1
2
3
4
Problematic
5
1 is Excellent, 5 is Problematic
Organization Skills
*
Excellent
1
2
3
4
Problematic
5
1 is Excellent, 5 is Problematic
Peer Relations
*
Excellent
1
2
3
4
Problematic
5
1 is Excellent, 5 is Problematic
Submit
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