Vanderbilt Initial Teacher Informant

Vanderbilt Initial Teacher Informant
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Person filling out the form

First NameLast Name
Relationship to Patient
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;

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. If there have been changes, focus most on the past week.

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 activities (not due to refusal 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 (school 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 games
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
18. Interrupts or intrudes in on others' conversations and/or activities
19. Loses temper
20. Actively defies or refuses to go along with adults' requests or rules
21. Is angry or resentful
22. Is spiteful and wants to get even
23. Bullies, threatens, or intimidates others
24. Starts physical fights
25. Often lies to get out of trouble, obtain goods or favors, or to avoid obligations (ie, "cons" others)
26. Is physically cruel to people
27. Has stolen things that have 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

Performance Academic Performance

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

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

Comments
Never = 0, Occasionally = 1, Often = 2, Very Often = 3

Excellent = 1, Above Average = 2, Average = 3, Somewhat a Problem = 4, Problematic = 5
Should be Empty:

Vanderbilt Initial Teacher Informant

Never = 0, Occasionally = 1, Often = 2, Very Often = 3