| Student | Date |
| Filled out by | Your role |
| School | District Grade |
The NICHQ (National Initiative for Children's Healthcare Quality) and American Academy of Pediatrics (AAP) have sponsored a set of tools for evaluating children for behavioral and emotional problems at school. Please complete the questionnaire based on your direct observations of this student in a school setting.
This form is designed for on-line submission. If you would like to download a PDF version for manual completion, go to:
Vanderbilt Teacher Scales (manual version) PDF
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never |
occasionally |
often |
very often |
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1. fails to give attention to details or makes careless mistakes in schoolwork |
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2. has difficulty sustaining attention to tasks |
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3. does not seem to listen when spoken to directly |
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4. does not follow through on instructions and fails to finish schoolwork |
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5. has difficulty organizing tasks/activities |
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6. avoids tasks that require sustained mental effort |
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7. loses things necessary for activities |
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8. is easily distracted by extraneous stimuli |
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9. is forgetful in daily activities |
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10. fidgets with hands or feet or squirms |
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11. leaves seat when remaining seated is expected |
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12. runs about or climbs excessively when remaining seated is expected |
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13. has difficulty playing or engaging in leisure activities quietly |
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14. is "on the go" or often acts as if "driven by a motor" |
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15. talks excessively |
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16. blurts out answers before questions have been completed |
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17. has difficulty waiting in line |
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18. interrupts or intrudes on others |
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19. loses temper |
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20. actively defies or refuses to comply with adult's requests or rules |
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21. is angry or resentful |
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22. is spiteful and vindictive |
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23. bullies, threatens, or intimidates others |
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24. initiates physical fights |
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25. lies to obtain goods for favors or to avoid obligations ("cons" others) |
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26. is physically cruel to people |
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27. has stolen items of nontrivial value |
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28. deliberately destroys others' property |
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29. is fearful, anxious or worried |
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30. is self-conscious and easily embarrassed |
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31. is afraid to try new things for fear of making mistakes |
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32. feels worthless or inferior |
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33. blames self for problems; feels guilty |
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34. feels lonely, unwanted, or unloved |
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35. is sad, unhappy, or depressed |
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School Performance and Demeanor
| Excellent | Above average | Average | Somewhat of a problem | Problematic | |
| Reading | |||||
| Math | |||||
| Written Expression | |||||
| Relationships with peers | |||||
| Following directions | |||||
| Disrupting classes | |||||
| Completing assignments | |||||
| Organizational skills |
Your comments:
If the student is known to be taking medication, are you aware of any side-effects?