southfieldpeds.com - ADHD Teacher Questionnaire

Teacher’s Name:

Class Time:

Class Name/Period:

Today’s Date:

Date

Child’s Name:

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

Symptoms

Rows	Never	Occasionally	Often	Very Often
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 schoolwork (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 (school assignments, pencils, or books)
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
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

1.Total

1.Never

1.Occasionally

1.Often

1.Very Often

2. Total

2. Never

2. Occasionally

2. Often

2. Very Often

3. Total

3. Never

3. Occasionally

3. Often

3. Very Often

4. Total

4. Never

4. Occasionally

4. Often

4. Very Often

5. Total

5. Never

5. Occasionally

5. Often

5. Very Often

6. Total

6. Never

6. Occasionally

6. Often

6. Very Often

7. Total

7. Never

7. Occasionally

7. Often

7. Very Often

8. Total

8. Never

8. Occasionally

8. Often

8. Very Often

9. Total

9. Never

9. Occasionally

9. Often

9. Very Often

10. Total

10. Never

10. Occasionally

10. Often

10. Very Often

11. Total

11. Never

11. Occasionally

11. Often

11. Very Often

12. Total

12. Never

12. Occasionally

12. Often

12. Very Often

13. Total

13. Never

13. Occasionally

13. Often

13. Very Often

14. Total

14. Never

14. Occasionally

14. Often

14. Very Often

15. Total

15. Never

15. Occasionally

15. Often

15. Very Often

16. Total

16. Never

16. Occasionally

16. Often

16. Very Often

17. Total

17. Never

17. Occasionally

17. Often

17. Very Often

18. Total

18. Never

18. Occasionally

18. Often

18. Very Often

19. Total

19. Never

19. Occasionally

19. Often

19. Very Often

20. Total

20. Never

20. Occasionally

20. Often

20. Very Often

21. Total

21. Never

21. Occasionally

21. Often

21. Very Often

22. Total

22. Never

22. Occasionally

22. Often

22. Very Often

23. Total

23. Never

23. Occasionally

23. Often

23. Very Often

24. Total

24. Never

24. Occasionally

24. Often

24. Very Often

25. Total

25. Never

25. Occasionally

25. Often

25. Very Often

26. Total

26. Never

26. Occasionally

26. Often

26. Very Often

27. Total

27. Never

27. Occasionally

27. Often

27. Very Often

28. Total

28. Never

28. Occasionally

28. Often

28. Very Often

29. Total

29. Never

29. Occasionally

29. Often

29. Very Often

30. Total

30. Never

30. Occasionally

30. Often

30. Very Often

31. Total

31. Never

31. Occasionally

31. Often

31. Very Often

32. Total

32. Never

32. Occasionally

32. Often

32. Very Often

33. Total

33. Never

33. Occasionally

33. Often

33. Very Often

34. Total

34. Never

34. Occasionally

34. Often

34. Very Often

35. Total

35. Never

35. Occasionally

35. Often

35. Very Often

Symptoms Total Never

Symptoms Total Occasionally

Symptoms Total Often

Symptoms Total Very Often

Academic Performance

Rows	Excellent	Average	Above Average	Somewhat of a Problem	Problematic
36. Reading
37. Mathematics
38. Written expression

36. Total

36. Excellent

36. Average

36. Above Average

36. Somewhat of a Problem

36. Problematic

37. Total

37. Excellent

37. Average

37. Above Average

37. Somewhat of a Problem

37. Problematic

38. Total

38. Excellent

38. Average

38. Above Average

38. Somewhat of a Problem

38. Problematic

Academic Performance Total Excellent

Academic Performance Total Average

Academic Performance Total Above Average

Academic Performance Total Somewhat of a Problem

Academic Performance Total Problematic

Classroom Behavioral Performance

Rows	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
39. Relationship with peers
40. Following directions
41. Disrupting class
42. Assignment completion
43. Organizational skills

39. Total

39. Excellent

39. Above Average

39. Average

39. Somewhat of a Problem

39. Problematic

40. Total

40. Excellent

40. Above Average

40. Average

40. Somewhat of a Problem

40. Problematic

41. Total

41. Excellent

41. Above Average

41. Average

41. Somewhat of a Problem

41. Problematic

42. Total

42. Excellent

42. Above Average

42. Average

42. Somewhat of a Problem

42. Problematic

43. Total

43. Excellent

43. Above Average

43. Average

43. Somewhat of a Problem

43. Problematic

Classroom Performance Total Excellent

Classroom Performance Total Above Average

Classroom Performance Total Average

Classroom Performance Total Somewhat of a Problem

Classroom Performance Total Problematic

Total Score

Comments:

NICHQ Vanderbilt — Teacher

Symptoms summary

Count of 'Never': {symptomsTotal}

Count of 'Occasionally': {symptomsTotal415}

Count of 'Often': {symptomsTotal416}

Count of 'Very Often': {symptomsTotal417}

Academic Performance Summary

Count of 'Excellent': {academicPerformance}

Count of 'Above Average': {academicPerformance423}

Count of 'Average': {academicPerformance422}

Count of 'Somewhat of a Problem': {academicPerformance424}

Count of 'Problematic': {academicPerformance425}

Classroom Behavioral Summary

Count of 'Excellent': {classroomPerformance}

Count of 'Above Average': {classroomBehavioral428}

Count of 'Average': {classroomPerformance429}

Count of 'Somewhat of a Problem': {classroomPerformance430}

Count of 'Problematic': {classroomPerformance431}

NICHQ Vanderbilt Assessment Scale

Performance

NICHQ Vanderbilt — Teacher

Symptoms summary

Academic Performance Summary

Classroom Behavioral Summary