NICHQ Vanderbilt Teacher Form

Fails to give attention to details or makes careless mistakes in schoolwork:
-NeverOccasionallyOftenVery Often

Has difficulty sustaining attention to tasks or activities:
-NeverOccasionallyOftenVery Often

Does not seem to listen when spoken to directly:
-NeverOccasionallyOftenVery Often

Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand):
-NeverOccasionallyOftenVery Often

Has difficulty organizing tasks and activities:
-NeverOccasionallyOftenVery Often

Avoids, dislikes, or is reluctant to engage in tasks that require sustained:
-NeverOccasionallyOftenVery Often

Loses things necessary for tasks or activities (toys, assignments, pencils, or books):
-NeverOccasionallyOftenVery Often

Is easily distracted by noises or other stimuli:
-NeverOccasionallyOftenVery Often

Is forgetful in daily activities:
-NeverOccasionallyOftenVery Often

Fidgets with hands or feet or squirms in seat:
-NeverOccasionallyOftenVery Often

Leaves seat in classroom or in other situations when remaining seated is expected:
-NeverOccasionallyOftenVery Often

Runs about or climbs excessively in situations when remaining seated is expected:
-NeverOccasionallyOftenVery Often

Has difficulty playing or engaging in leisure activities quietly:
-NeverOccasionallyOftenVery Often

Is “on the go” or often acts as if “driven by a motor”:
-NeverOccasionallyOftenVery Often

Talks excessively:
-NeverOccasionallyOftenVery Often

Blurts out answers before questions have been completed:
-NeverOccasionallyOftenVery Often

Has difficulty waiting in line:
-NeverOccasionallyOftenVery Often

Interrupts or intrudes in on others (eg, butts into conversations/games):
-NeverOccasionallyOftenVery Often

Loses temper:
-NeverOccasionallyOftenVery Often

Actively defies or refuses to comply with adult’s requests or rules:
-NeverOccasionallyOftenVery Often

Is angry or resentful:
-NeverOccasionallyOftenVery Often

Is spiteful and vindictive:
-NeverOccasionallyOftenVery Often

Bullies, threatens, or intimidates others:
-NeverOccasionallyOftenVery Often

Initiates physical fights:
-NeverOccasionallyOftenVery Often

Lies to to obtain goods for favors or to avoid obligations (ie,“cons” others):
-NeverOccasionallyOftenVery Often

Is physically cruel to people:
-NeverOccasionallyOftenVery Often

Has stolen items of nontrivial value:
-NeverOccasionallyOftenVery Often

Deliberately destroys others’ property:
-NeverOccasionallyOftenVery Often

Is fearful, anxious, or worried:
-NeverOccasionallyOftenVery Often

Is self-conscious or easily embarrassed:
-NeverOccasionallyOftenVery Often

Is afraid to try new things for fear of making mistakes:
-NeverOccasionallyOftenVery Often

Feels worthless or inferior:
-NeverOccasionallyOftenVery Often

Blames self for problems, feels guilty:
-NeverOccasionallyOftenVery Often

Feels lonely, unwanted, or unloved; complains that “no one loves him or her”:
-NeverOccasionallyOftenVery Often

Is sad, unhappy, or depressed:
-NeverOccasionallyOftenVery Often

Academic Performance

Reading:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Writing expressions:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Mathematics:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Classroom Behavioral Performace

Relationship with peers:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Following directions:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Disrupting class:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Assignment completion:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Organizational skills:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Total number of questions scored 2 or 3 in questios 1-9:

Total number of questions scored 2 or 3 in questions 10–18:

Total Symptom Score for questions 1–18:

Total number of questions scored 2 or 3 in questions 19–26:

Total number of questions scored 2 or 3 in questions 27–40:

Total number of questions scored 2 or 3 in questions 41–47:

Total number of questions scored 4 or 5 in questions 48–55:

Average Performance Score: