TEACHER Informant

ADHD Vanderbilt Assessment Scale

Student Today’s date

Teacher Grade Class

Directions: Please rate the above student’s performance in your class on the following symptom list. The form should take about 10 or 15 minutes to complete. You may give the completed form to the parent; or fax or mail it to me at the above address. I would also be grateful for any WRITTEN comments you might make. Thank you very much!

-- Dr. Epstein

	*Symptom*	Never	Occasionally	Often	Very Often
1	Fails to give attention to details, or makes careless mistakes in schoolwork	0	1	2	3
2	Has difficulty sustaining attention to tasks or activities	0	1	2	3
3	Does not seem to listen when spoken to directly	0	1	2	3
4	Does not follow through on instructions, and fails to finish schoolwork (not due to oppositional behavior or failure to understand)	0	1	2	3
5	Has difficulty organizing tasks and activities	0	1	2	3
6	Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort	0	1	2	3
7	Loses things necessary for tasks or activities (school assignments, pencils, or books)	0	1	2	3
8	Is easily distracted by extraneous stimuli	0	1	2	3
9	Is forgetful in daily activities	0	1	2	3
10	Fidgets with hands or feet, or squirms in seat	0	1	2	3
11	Leaves seat in classroom or in other situations in which remaining seated is expected	0	1	2	3
12	Runs about or climbs excessively in situations in which remaining seated is expected	0	1	2	3
13	Has difficulty playing or engaging in leisure activities quietly	0	1	2	3
14	Is "on the go" or often acts as if " driven by a motor"	0	1	2	3
15	Talks excessively	0	1	2	3
16	Blurts out answers before questions have been completed	0	1	2	3
17	Has difficulty waiting in line	0	1	2	3
18	Interrupts or intrudes on others (eg, butts into conversations/games)	0	1	2	3
19	Loses temper	0	1	2	3
20	Actively defies or refuses to comply with adults' requests or rules	0	1	2	3
21	Is angry or resentful	0	1	2	3
22	Is spiteful and vindictive	0	1	2	3
23	Bullies, threatens, or intimidates others	0	1	2	3
24	Initiates physical fights	0	1	2	3
25	Lies to obtain goods for favors, or to avoid obligations ("cons" others)	0	1	2	3
26	Is physically cruel to people	0	1	2	3
27	Has stolen items of nontrivial value	0	1	2	3
28	Deliberately destroys others' property	0	1	2	3
29	Is fearful, anxious, or worried	0	1	2	3
30	Is self-conscious or easily embarrassed	0	1	2	3
31	Is afraid to try new things for fear of making mistakes	0	1	2	3
32	Feels worthless or inferior	0	1	2	3
33	Blames self for problems; feels guilty	0	1	2	3
34	Feels lonely, unwanted, or unloved; complains that "no one loves him or her"	0	1	2	3
35	Is sad, unhappy, or depressed	0	1	2	3

	*Academic Performance*	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
36	Reading	1	2	3	4	5
37	Mathematics	1	2	3	4	5
38	Written expression	1	2	3	4	5

	*Classroom Behavior*	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
39	Relationship with peers	1	2	3	4	5
40	Following directions	1	2	3