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Child's Name
*
First Name
Last Name
School Name
*
School currently attending.
School Email
*
example@example.com
Teacher's Name
*
First Name
Last Name
Teacher's Email
*
example@example.com
Grade
*
Today's Date
-
Day
-
Month
Year
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 medication
was not on medication
not sure
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Rating Scale
*
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
School work
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Excellent
Above average
Average
Somewhat a Problem
Problematic
19.Reading
20. Mathematics
21. Written Expression
22. Relationship with peers
23. Following direction
24. Disrupting class
25. Assignment completion
26. Organizational skills
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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
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