Child's Behavior Assessment form

Teacher's Name

First NameLast Name

Child's Name

First NameLast Name

Grade

Today's Date

MonthDayYear

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 medicationwas not on medicationnot 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

Vanderbilt Assessment-Teacher Informant