Teacher Vanderbilt

Teacher Vanderbilt

Must be completed prior to the first visit and before 6 month follow up visit with doc.
Teacher's Name:
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Class Time:

:HourMinutesAM/PM Option
Child's Name:
Class Name/Period:
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:
- 1. Fails to give attention to details or makes careless mistakes in schoolwork
- 2. Has difficulty sustaining attention to tasks or activities
- 3. Does not seem to listen when spoken to directly
- 4. Does not follow through on instructions and fails to finish school work (not due to oppositional behavior or failure to understand)
- 5. Has difficulty organizing tasks and activities
- 6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
- 7. Loses things necessary for tasks or activities
- 8. Is easily distracted by extraneous stimuli
- 9. Is forgetful in daily activities
- 10. Fidgets with hands or feet or squirms in seat
- 11. Leaves seat in classroom or in other situations in which remaining seated is expected
- 12. Runs about or climbs excessively in situations in which remaining seated is expected
- 13. Has difficulty playing or engaging in leisure activities quietly
- 14. Is on the go or often acts as if driven by a motor
- 15. Talks excessively
- 16. Blurts out answers before questions have been completed
- 17. Has difficulty waiting in line
- 18. Interrupts or intrudes on others (eg. butts into conversations/games)
- 19. Loses temper
- 20. Actively defies or refuses to comply with adult's requests or rules
- 21. Is angry or resentful
- 22. Is spiteful and vindictive
- 23. Bullies, threatens, or intimidates others
- 24. Initiates physical fights
- 25. Lies to obtain goods for favors or to avoid obligations (eg, cons others)
- 26. Is physically cruel to people
- 27. Has stolen items of nontrivial value
- 28. Deliberately destroys others property
- 29. Is fearful, anxious, or worried
- 29. Is fearful, anxious, or worried
- 30. Is self-conscious or easily embarrassed
- 31. Is afraid to try new things for fear of making mistakes
- 32. Feels worthless or inferior
- 33. Blames self for problems; feels guilty
- 34. Feels lonely, unwanted, or unloved; complains that no one loves him or her
- 35. Is sad, unhappy, or depressed
- 36. Reading
- 37. Mathematics
- 38. Written expression
- 39. Relationship with peers
- 40. Following directions
- 41. Disrupting class
- 42. Assignment completion
- 43. Organizational skills
- Comments:
- Heading
- 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:
- Should be Empty:

Teacher Vanderbilt

Is this evaluation based on a time when the child:

Heading

For Office Use Only