NICHQ Vanderbilt ASSESSMENT Scale TEACHER Informant

Associated Therapists Inc.
Julio J. Guerra, Ph.D.
(714) 898-0362 Corporate Office
(714) 893-3267 Fax
www.associatedtherapists.com

Today's Date:

* +

Teacher Name: *

Class Time:

Class Time/Period:

Child's First Name: *

Child's Last Name: *

Grade Level:

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 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	Very Often
1. Fails to give attention 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 instruction and fails to finish school work (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

	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 (e.g., butts into conversations/games).	Never	Occasionally	Often	Very Often

	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 (e.g., "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 other's property.	Never	Occasionally	Often	Very Often

	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/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	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	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

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Form by NICHQ
National Inititative for Children's Healthcare Quality (2002).

Thank you for your time and information. The information will be securely sent to the Associated Therapists Office and will be forwarded to Dr. Guerra.