NICHQ Vanderbilt Assessment Follow-up
TEACHER Informant
Today's Date
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Month
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Day
Year
Date
Child's Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Parent's Name
First Name
Last Name
Parent's Phone Number
Please enter a valid phone number.
Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months.
This evaluation was based on a time when the child
was on medication
was not on medication
not sure?
Symptoms
Never (0)
Occasionally (1)
Often (2)
Very Often (3)
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 when given directions 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
Excellent (1)
Above Average (2)
Average (3)
Somewhat of a Problem (4)
Problematic (5)
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:
Has your child experienced any of the following side effects or problems in the past week?
None
Mild
Moderate
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:
For Office Use Only
Total Symptom Score for questions 1–18:
Average Performance Score:
Submit
Should be Empty: