Vanderbilt Teacher Follow-Up Form | Pediatric Associates

Vanderbilt Assessment - Teacher Informant - Follow -up

Child's Name *

First name

Last name

Date of Birth

Month

Day

Year

Completed By *

First Name

Last Name

Class/Subject

Date of Appointment

Child's Provider

Each rating should be considered in the context of what is appropriate for the age of the child.

1. Does not pay attention to details or makes careless mistakes, such as in home-work

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 schoolwork (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 does not want to start tasks that require ongoing mental effort

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

8. Is easily distracted by noises or other stimuli

Never

Occasionally

Often

Very Often

9. Is forgetful in daily activities

Never

Occasionally

Often

Very Often

10. Fidgets with hands or feet or squirms in seat

Never

Occasionally

Often

Very Often

11. Leaves seat when remaining seated is expected

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

13. Has difficulty playing or beginning quiet play activities

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 too much

Never

Occasionally

Often

Very Often

16. Blurts out answers before questions have been completed

Never

Occasionally

Often

Very Often

17. Has difficulty waiting his/her turn

Never

Occasionally

Often

Very Often

18. Interrupts or intrudes in on others (butts into conversations or games)

Never

Occasionally

Often

Very Often

19. Loses temper

Never

Occasionally

Often

Very Often

20. Actively defies or refuses to comply with adults’ 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 (“cons” other

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 others’ property

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

Classroom Behavior

Additional Comments

I understand that the information submitted may include personal health information and consent to its secure storage and use.

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Vanderbilt Assessment - Teacher Informant - Follow -up