Vanderbilt Assessment Scale-Teacher Informant "*" indicates required fields NICHQ Vanderbilt Assessment Scale-TEACHER InformantToday's Date* MM slash DD slash YYYY Teacher's Name:* First Last Class Time:* Grade Level:*Pre-K 3Pre-K 4Kindergarten123456789101112Class Name/Period:* Child's Name:* First Last Client Date of birth* MM slash DD slash YYYY Directions: Each rating should be considered in the context of what is appropriate for the age of your 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 evaluate behaviors:* Is this evaluation based on a time when the child* was on medication was not on medication No sure? Symptoms1. Fails to give attention to details or makes careless mistakes in schoolwork* Never Occasionally Often Very Often 2. Has difficulty sustaining attention to task or activites* 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 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 noises or other 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 in on others’(eg, butts in 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 request 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 Performance36. 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 Performance39. 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:For Office Use OnlyTotal number of questions scored 2 or 3 in questions 1-9:Total number of questions scored 2 or 3 in question 10-18:Total Symptom Score for questions 1-18:Total number of questions scored 2 or 3 in questions 19-28:Total number of questions scored 2 or 3 in questions 29-35:Total number of questions scored 4 or 5 in questions 36-43:Average Performance 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 - 110211-19/rev1102
