Type a question
Name of Student
First Name
Last Name
Person Completing the Form
Date Completed
/
Month
/
Day
Year
Date
Subject Taught
Time of Day:
Morning
Afternoon
Other
Not at All
Just a Little
Quite a Bit
Very Much
1. Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks
2. Often has difficulty sustaining attention in tasks or play activities
3. Often does not seem to listen when spoken to directly
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties
5. Often has difficulty organizing tasks and activities
6. Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort
7. Often loses things necessary for activities (e.g., toys, school assignments, pencils, or books)
8. Often is distracted by extraneous stimuli
9. Often is forgetful in daily activities
10. Often has difficulty maintaining alertness, orienting to requests, or executing directions
Not at All
Just a Little
Quite a Bit
Very Much
11. Often fidgets with hands or feet, or squirms in seat
12. Often leaves seat in classroom or in other situations in which remaining seated is expected
13. Often runs about or climbs excessively in situations in which it is inappropriate
14. Often has difficulty playing or engaging in leisure activities quietly
15. Often is “on the go” or often acts as if “driven by a motor”
16. Often talks excessively
17. Often blurts out answers before questions have been completed
18. Often has difficulty awaiting turn
19. Often interrupts or intrudes on others (e.g., butts into conversations/games)
20. Often has difficulty sitting still, being quiet, or inhibiting impulses in the classroom or at home
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