NICHQ Vanderbilt ADHD Assessment Follow Up - Teacher Informant

Teacher's Name*

First NameLast Name

Class Time*

Class Name/Period*

Today's Date*

Date

Child's Name*

First NameLast Name

Grade Level*

Teacher's Email (for submission confirmation)*

example@example.com

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 last assessment scale was filled out.

Please indicate the number of weeks or months you have been able to evaluate the behaviors*

Number of Weeks or Months

Is this evaluation based on a time when the child*

was on medicationwas not on medicationnot sure

Symptoms

0-Never

1-Occasionally

2-Often

3-Very Often

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

2. Has difficulty keeping attention to what needs to be done*

3. Does not seem to listen when spoken to directly*

4. Does not follow through on instructions and fails to finish activities (not due to refusal or failure to understand)*

5. Has difficulty organizing tasks and activities*

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

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

8. Is easily distracted by noises or other stimuli*

9. Is forgetful in daily activities*

10. Fidgets with hands or feet or squirms in seat*

11. Leaves seat when remaining seated is expected*

12. Runs about or climbs too much when remaining seated is expected*

13. Has difficulty playing or beginning quiet play activities*

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

15. Talks too much*

16. Blurts out answers before questions have been completed*

17. Has difficulty waiting his or her turn*

18. Interrupts or intrudes in on others’ conversations and/or activities*

Performance	1-	2-	3-	4-	5-
	Excellent	Above Average	Average	Somewhat of a Problem	Problematic

19. Reading*

20. Mathematics*

21. Written expression*

22. Relationship with peers*

23. Following direction*

24. Disrupting class*

25. Assignment completion*

26. Organizational skills*

Side Effects

Are these side effects currently a problem?

Has the child experienced any of the following side effects or problems in the past week?

0-None

1-Mild

2-Moderate

3-Severe

Headache*

Stomachache*

Change of appetite—explain below*

Trouble sleeping*

Irritability in the late morning, late afternoon, or evening—explain below*

Socially withdrawn—decreased interaction with others*

Extreme sadness or unusual crying*

Dull, tired, listless behavior*

Tremors/feeling shaky*

Repetitive movements, tics, jerking, twitching, eye blinking—explain below*

Picking at skin or fingers, nail biting, lip or cheek chewing—explain below*

Sees or hears things that aren’t there*

Explain/Comments:

Please Return This Form To

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Fax Number

Area CodePhone Number

**The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circum-stances, may be appropriate.