NICHQ Vanderbilt Assessment Follow up — TEACHER Informant

Step 1 of 4

Before you start: you will need the child's date of birth and the parent's mobile number from the parent before starting this form. These must match the details held by the clinic, or the form cannot be submitted.

Basic Information

Teacher's Name(Required)

First Name Last Name

Class Date(Required)

Class Time(Required)

Class Name / Period(Required)

Today's Date(Required)

Child's First Name(Required)

First Name Last Name

Child's Date of Birth(Required)

Please enter these exactly as provided to you by the clinic or the parent.

Parent's Mobile Number(Required)

Please enter these exactly as provided to you by the clinic or the parent.

Grade Level(Required)

Please indicate the number of weeks or months you have been able to evaluate the behaviours:(Required)

Is this evaluation based on a time when the child(Required)

Symptoms

1. Does not pay attention to details or makes careless mistakes with, for example, homework(Required)

2. Has difficulty keeping attention to what needs to be done(Required)

3. Does not seem to listen when spoken to directly(Required)

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)(Required)

5. Has difficulty organizing tasks and activities(Required)

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort(Required)

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)(Required)

8. Is easily distracted by noises or other stimuli(Required)

9. Is forgetful in daily activities(Required)

10. Fidgets with hands or feet or squirms in seat(Required)

11. Leaves seat when remaining seated is expected(Required)

12. Runs about or climbs too much when remaining seated is expected(Required)

13. Has difficulty playing or beginning quiet play activities(Required)

14. Is “on the go” or often acts as if “driven by a motor”(Required)

15. Talks too much(Required)

16. Blurts out answers before questions have been completed(Required)

17. Has difficulty waiting his or her turn(Required)

18. Interrupts or intrudes in on others’ conversations and/or activities(Required)

Kids Health Space