NICHQ Vanderbilt Assessment Scale — TEACHER Informant

Step 1 of 3

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 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. Fails to give attention to details or makes careless mistakes in schoolwork(Required)

2. Has difficulty sustaining attention to tasks or activities(Required)

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

4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand)(Required)

5. Has difficulty organizing tasks and activities(Required)

6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort(Required)

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

8. Is easily distracted by extraneous stimuli(Required)

9. Is forgetful in daily activities(Required)

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

11. Leaves seat in classroom or in other situations in which remaining seated is expected(Required)

12. Runs about or climbs excessively in situations in which remaining seated is expected(Required)

13. Has difficulty playing or engaging in leisure activities quietly(Required)

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

15. Talks excessively(Required)

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

17. Has difficulty waiting in line(Required)

18. Interrupts or intrudes on others (eg, butts into conversations/games)(Required)

19. Loses temper(Required)

20. Actively defies or refuses to comply with adult’s requests or rules(Required)

21. Is angry or resentful(Required)

22. Is spiteful and vindictive(Required)

23. Bullies, threatens, or intimidates others(Required)

24. Initiates physical fights(Required)

25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others)(Required)

26. Is physically cruel to people(Required)

27. Has stolen items of nontrivial value(Required)

28. Deliberately destroys others’ property(Required)

29. Is fearful, anxious, or worried(Required)

30. Is self-conscious or easily embarrassed(Required)

31. Is afraid to try new things for fear of making mistakes(Required)

32. Feels worthless or inferior(Required)

33. Blames self for problems; feels guilty(Required)

34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”(Required)

35. Is sad, unhappy, or depressed(Required)

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