ADHD Teacher Initial Form

Today's Date

Date

Child's Name

First NameLast Name

Grade Level

Teacher's Name

First NameLast Name

Class Time

Class Name/Period:

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 evalute the behaviors

Weeks/Months

Is this evaluation based on a time when the child

was on medicationwas not on medicationnot sure?

Symptoms

	(0) Never	(1) Occasionally	(2) Often	(3) Very Often
1. Fails to give attention to details or makes careless mistakes in school work
2. Has difficulty sustaining attention to tasks or activities
3. Does not seem to listen when spoken to directly
4. Does not follow through when given directions 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 (toys, assignments, pencils, or books)
8. Is easily distraced by extraneous stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when reamining seated is expected
12. Runs about or climbs too much when 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 in on others' conversation and/or activites
19. Loses Temper
20. Actively defies or refuses to comply with adult's requestss 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 (ef, "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

Academic Performance

	(1) Excellent	(2) Above Average	(3) Average	(4) Somewhat of a Problem	(5) Problematic
36. Reading
37. Mathematics
38. Written expression

Classroom Behavioral Performance

	(1) Excellent	(2) Above Average	(3) Average	(4) Somewhat of a Problem	(5) Problematic
39. Relationship with peers
40. Following directions
41. Disrupting class
42. Assignment completion
43. Organizational skills

Comments:

For Office Use Only

Total number of questions scored 2 or 3 in questions 1-9:   Score
Total number of questions scored 2 or 3 in questions 10-18:   Score
Total Symptom Score for questions 1-18:   Score
Total number of questions scored 2 or 3 in questions 19-28:   Score
Total number of questions scored 2 or 3 in questions 29-35:   Score
Total number of questions scored 4 or 5 in questions 36-43:   Score
Average Performance Score:   Score

The information contained in this publication should not be used as a substitute for the
medical care and advice of your pediatrician. There may be variations in treatment that
your pediatrician may recommend based on individual facts and circumstances.
Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s
Healthcare Quality
Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD.
Revised - 0303

NICHQ Vanderbilt Assessment Scale