NICHQ Vanderbilt ADHD Assessment Scale - 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 beginning of the school year.

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

2. Has difficulty sustaining attention to tasks or activities*

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

4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior 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 (school 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 excessively in situations in which remaining seated is expected*

13. Has difficulty playing or engaging in leisure activities quietly*

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

15. Talks excessively*

16. Blurts out answers before questions have been completed*

17. Has difficulty waiting in line*

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

19. Loses temper*

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

21. Is angry or resentful*

22. Is spiteful and vindictive*

23. Bullies, threatens, or intimidates others*

24. Initiates physical fights*

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

26. Is physically cruel to people*

27. Has stolen items of nontrivial value*

28. Deliberately destroys others’ property*

29. Is fearful, anxious, or worried*

30. Is self-conscious or easily embarrassed*

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

32. Feels worthless or inferior*

33. Blames self for problems; feels guilty*

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

35. Is sad, unhappy, or depressed*

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

36. Reading*

37. Mathematics*

38. Written expression*

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

39. Relationship with peers*

40. Following directions*

41. Disrupting class*

42. Assignment completion*

43. Organizational skills*

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 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.