Vanderbilt Assessment-Teacher Informant
Teacher's Name
First Name
Last Name
Child's Name
First Name
Last Name
Grade
Today's Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
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1992
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1990
1989
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1986
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1983
1982
1981
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Class Time
Class Name/Period
Please indicate the number of weeks or months you have been able to evaluate the behaviors:
Is the evaluation based on a time when the child:
*
was on medication
was not on medication
not sure?
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.
Never
Occasionally
Often
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 instruction 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 is reluctant to engage in tasks that require sustained mental effort
7. Loses things necessary for tasks or activities (school assignments, pencils, or books)
8. Is easily distracted by extraneous stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining in seated is expected
12. Runs about or climbs excessively when 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 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 (butts into conversations or games)
19. Loses temper
20. Actively defies or refuses to comply with adults’ 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 (“cons” other
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/her”
35. Is sad, unhappy, or depressed
Academic Performance
Excellent
Above Average
Average
Somewhat of
a Problem
Problematic
Reading
Mathematics
Written Expression
Classroom Behavior
Excellent
Above Average
Average
Somewhat of
a Problem
Problematic
Relationship with Peers
Following Directions/Rules
Disrupting Class
Assignment Completion
Organizational Skills
Submit
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