Teacher Questionnaire

NICHQ Vanderbilt Assessment Scale

Teacher Information

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.

Teacher's Name

Child's Name

Grade Level

Class Name/Period

Class Time

Weeks or months you have been able to evaluate the behaviors

Is this evaluation based on a time when the child:

Was on medication

Was not on medication

Not sure

Symptoms

Never, Occasionally, Often, or Very Often

1. Fails to give attention to details or makes careless mistakes in schoolwork

Never

Occasionally

Often

Very Often

2. Has difficulty sustaining attention to tasks or activities

Never

Occasionally

Often

Very Often

3. Does not seem to listen when spoken to directly

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

5. Has difficulty organizing tasks and activities

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

8. Is easily distracted by extraneous stimuli

Never

Occasionally

Often

Very Often

9. Is forgetful in daily activities

Never

Occasionally

Often

Very Often

10. Fidgets with hands or feet or squirms in seat

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

13. Has difficulty playing or engaging in leisure activities quietly

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

15. Talks excessively

Never

Occasionally

Often

Very Often

16. Blurts out answers before questions have been completed

Never

Occasionally

Often

Very Often

17. Has difficulty waiting in line

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

19. Loses temper

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

21. Is angry or resentful

Never

Occasionally

Often

Very Often

22. Is spiteful and vindictive

Never

Occasionally

Often

Very Often

23. Bullies, threatens, or intimidates others

Never

Occasionally

Often

Very Often

24. Initiates physical fights

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

26. Is physically cruel to people

Never

Occasionally

Often

Very Often

27. Has stolen items of nontrivial value

Never

Occasionally

Often

Very Often

28. Deliberately destroys others’ property

Never

Occasionally

Often

Very Often

29. Is fearful, anxious, or worried

Never

Occasionally

Often

Very Often

30. Is self-conscious or easily embarrassed

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

32. Feels worthless or inferior

Never

Occasionally

Often

Very Often

33. Blames self for problems; feels guilty

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

35. Is sad, unhappy, or depressed

Never

Occasionally

Often

Very Often

Academic Performance

Excellent, Above Average, Average, Somewhat of a Problem, or Problematic

36. Reading

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

37. Mathematics

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

38. Written expression

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Classroom Behavioral Performance

Excellent, Above Average, Average, Somewhat of a Problem, or Problematic

39. Relationship with peers

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

40. Following directions

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

41. Disrupting class

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

42. Assignment completion

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

43. Organizational skills

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Comments

Optional

Comments

NICHQ Vanderbilt Assessment Scale. 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.