Teacher Follow-up ADHD form

Teacher & Learner Details
Teacher role*

Class/Homeroom teacherSubject teacher (High School)Learning support / remedialOther
School Name*
School currently attending.
Grade*
Subject taught
Teacher's Name*

First NameLast Name
Teacher's Email*
example@example.com
Parent's Email*
Completing this field will notify the parents that you have kindly filled out the form. Please note that the contents of the form will remain confidential; only a notification of completion will be sent to the parents.
Child's Name*

First NameLast Name
School Email*
example@example.com
Grade*
Today's Date

DayMonthYear
Date
Additional information about type of class
Normal stream. Remedial. Or specialised class
Please indicate in months time you have been able to evaluate the behaviours:*
Is this evaluation based on a time when the child is on medication?*

was on medicationwas not on medicationnot sure
I have read and accepted the terms of use, privacy policy, and sharing of personal information(including email addresses) policy on the drflett.com website in terms of the South African POPI Act. Please note the information collected in this form maybe be automatically removed once the clinical assessment has been completed to comply with drflett's information privacy policy (Please refer to the Privacy Statement at the bottom menu of drflett.com).*

I accept

Rating Scale.

How often did you observe the following during lessons/class activities?

10 Questions *

	Never	Occasional	Often	Very Often
1.Does not pay attention to details or makes careless mistakes with, for example, homework
2. Has difficulty keeping attention to what needs to be done
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand).
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
8. Is easily distracted by noises or other stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining seated is expected
12. Runs about or climbs too much when remaining seated is expected
13. Has difficulty playing or beginning quiet play activities
14. Is “on the go” or often acts as if “driven by a motor”
15. Talks too much
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his or her turn (waiting in line)
18. Interrupts or intrudes on others’ conversations and/or activities

Context (Last 2 School Weeks)
Overall change*

Much worseWorseBetterMuch betterUnsure
Medication during school hours?

YesNoNot sure
Any changes at school recently?*

New teacher / new grade / timetable changesNew accommodations/supportRecent assessment results sharedMajor family stressors (teacher aware)None / Not sure
Classroom Functioning (10 items)

Please rate the last 2 school weeks (or since the last review).

Schoolwork Ratings

Time-of-Day Pattern
Best time of day*

Early morningMid-morningAfter breakLast periodVariesUnsure
Most difficult time*

Early morningMid-morningAfter breakLast periodVariesUnsure
If you can, specify a time window (e.g., 11:00–12:00)
Possible Side Effects Noticed at School
Checkboxes (tick all that apply)

Appetite noticeably reduced at break/lunchLooks unusually quiet/flatMore irritable/tearful than baselineHeadache/stomach-ache complaintsNew/increased tics or repetitive movementsMore anxious/on edgeNot observed / unsure
Supports & Accommodations
Currently in place

Preferential seatingInstructions written downReduced copying / notes providedCheck-ins / prompt cardExtra timeMovement breaksBreak tasks into stepsReduced quantity (same learning goal)Typing / assistive techSmall group / remedial supportOther: (Short text)
What would help most now? (select max 3)*

Preferential seatingInstructions written downReduced copying / notes providedCheck-ins / prompt cardExtra timeMovement breaksBreak tasks into stepsReduced quantity (same learning goal)Typing / assistive techSmall group / remedial supportOther: (Short text)
In One Sentence Each
One thing that improved most: Fill the Blank
One thing still most difficult: Fill the blank
Top 1–2 priorities for the next month: Fill the blank
In my subject, the single biggest barrier is: Fill the blank
Subject context
How many lessons per week do you teach this learner?

1234+
Biggest demand in your subject

Note-takingWritten paragraphs/essaysProblem solvingPractical workTests/examsHomework volumeOther

Time-of-Day Pattern
Best time of day*

Early morningMid-morningAfter breakLast periodVariesUnsure
Most difficult time*

Early morningMid-morningAfter breakLast periodVariesUnsure
If you can, specify a time window (e.g., 11:00–12:00)
Biggest Barrier
In my subject, the single biggest barrier is: Fill the blank

Instructions: Please describe what you see as this child's primary problems in each area and describe the effects of this child’s problems in that area over the past three months*

	Never	Occasional	Often	Very Often
1. How do this child's problems affect their relationship with other children?
2. How do this child's problems affect their relationship with the teacher
3. How do this child's problems affect their academic progress
4. How do this child's problems affect their self-esteem.
5. Overall severity of this child's problem in the overall need for treatment.
6. How your child's problems affect his or her relationship with playmates.

7. Regardless of whether this child is popular or unpopular with peers, does he or she have a special, close "best friend" that he or she has kept for more than a few months?*

YESNO

Are there specific areas where you think adjustments might be needed?

Name of medication, dose of each tablet, total dose per day if you know

	Medication	Dosage per tablet	Dosage school morning	Dosage school Lunchtime
Medications
Medications
Medications

Explain/Comments:
Additional comments
Inattention
Should be Empty:

	Never	Sometimes	Often	Very often	Not observed / not applicable
1. Attention: Stayed on task during teacher instruction (without repeated prompts).
2. Initiation: Started work within 1–2 minutes of instructions.
3. Directions: Followed 2–3 step instructions accurately.
4. Completion: Finished classwork within the time allowed.
5. Pace: Worked at an appropriate pace (not excessively slow or rushed).
6. Made avoidable mistakes from inattention.
7. Organisation: Managed books/materials/diary reliably.
8. Written output: Produced enough written work to show understanding.
9. Impulse/disruption: Interrupted/called out/left seat/disrupted learning.
10. Emotional regulation: Managed frustration/setbacks without escalation or shutdown.

	Excellent	Above average	Average	Somewhat a Problem	Problematic
11.Reading
12.Mathematics
13. Written Expression
14. Relationship with peers
15. Following direction
16. Disrupting class
17. Assignment completion
18. Organisational skills

	Above grade	At grade	Below grade	Unsure	N/A
11.Reading
12.Mathematics
13. Written Expression
14. Relationship with peers
15. Following direction
16. Disrupting class
17. Assignment completion
18. Organisational skills

	Above grade	At grade	Below grade	Unsure	N/A
Reading
Mathematics
Written Expression

	Independent	Needs some prompting	Needs frequent prompting	Needs 1:1 to complete	N/A
Reading tasks (e.g., comprehension questions)
Maths tasks (classwork/tests)
Writing tasks (paragraphs/extended writing)

	0	1	2	3	N/A
Responsiveness
Starts work promptly
Stays on task during explanations
Follows instructions in this subject
Completes classwork in time
Produces enough written output / work shown
Hands in homework/assignments on time
Manages frustration / accepts correction without escalation

Teacher & Learner Details

Rating Scale.

Context (Last 2 School Weeks)

Classroom Functioning (10 items)

Schoolwork Ratings

Time-of-Day Pattern

Possible Side Effects Noticed at School

Supports & Accommodations

In One Sentence Each

Subject context

Time-of-Day Pattern

Biggest Barrier