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NICHQ Vanderbilt Assessment Scale – TEACHER Informant
Michael
2024-02-21T10:10:28-06:00
NICHQ VANDERBILT ASSESSMENT SCALE
TEACHER INFORMANT
"
*
" indicates required fields
STUDENT INFORMATION
Student
*
First
Last
Teacher
*
First
Last
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Date of Birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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Date
MM slash DD slash YYYY
Class Name / Period
*
Class Time
*
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
Grade Level
*
K
1
2
3
4
5
6
7
8
9
10
11
12
Time you have been able to evaluate the behaviors
*
1 week
2 weeks
3 weeks
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months or greater
This evaluation based on a time when the child
*
was on medication
was not on medication
not sure
SYMPTOM ASSESSMENT
Each rating should be considered in the context of what is appropriate for the age of the children you are rating.
1. Fails to give attention to details or makes careless mistakes in schoolwork.
*
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 is reluctant to engage in tasks that require sustaining mental effort.
*
Never
Occasionally
Often
Very Often
7. Loses things necessary for tasks or activities like school assignments, pencils, or books.
*
Never
Occasionally
Often
Very Often
8. Is easily distracted by extraneous 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 in classroom or in other situations in which remaining seated is expected.
*
Never
Occasionally
Often
Very Often
12. Runs about or climbs excessively in situations in which remaining seated is expected.
*
Never
Occasionally
Often
Very Often
13. Has difficulty playing or engaging in leisure activities quietly.
*
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 excessively.
*
Never
Occasionally
Often
Very Often
16. Blurts out answers before questions have been completed.
*
Never
Occasionally
Often
Very Often
17. Has difficulty waiting in line.
*
Never
Occasionally
Often
Very Often
18. Interrupts or intrudes on others, e.g., 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, i.e., “cons” others.
*
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
36. Reading
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
37. Mathematics
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
38. Written Expression
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
CLASSROOM BEHAVIORAL PERFORMANCE
39. Relationship With Peers
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
40. Following Directions / Rules
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
41. Disrupting Class
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
42. Assignment Completion
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
43. Organizational Skills
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
Comments
SCORES
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PREDOMINANTLY INATTENTIVE SUBTYPE
Total number of questions scored 2 or 3 in questions 1–9:
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PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE
Total number of questions scored 2 or 3 in questions 10–18:
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Total Symptom Score for questions 1–18:
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OPPOSITIONAL-DEFIANT / CONDUCT DISORDER SCREEN
Total number of questions scored 2 or 3 in questions 19–28:
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ANXIETY / DEPRESSION SCREEN
Total number of questions scored 2 or 3 in questions 29–35:
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Average Performance Score:
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F76 Tie
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F77 Tie
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F78 Tie
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F80 Tie
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F81 Tie
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F82 Tie
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F83 Tie
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F84 Tie
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ACADEMIC PERFORMANCE
Total number of questions scored 4 or 5 in questions 36–43:
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PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE
Must score a 2 or 3 on 6 out of 9 items on questions 10–18 AND Score a 4 or 5 on any of the Performance questions 36–43.
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PREDOMINANTLY INATTENTIVE SUBTYPE SCORE
Must score a 2 or 3 on 6 out of 9 items on questions 1–9 AND Score a 4 or 5 on any of the Performance questions 36–43.
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ADHD COMBINED INATTENTION / HYPERACTIVITY
Requires the above criteria on both inattention and hyperactivity / impulsivity.
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OPPOSITIONAL-DEFIANT / CONDUCT DISORDER SCREEN
Must score a 2 or 3 on 3 out of 10 items on questions 19–28 AND Score a 4 or 5 on any of the Performance questions 36–43.
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ANXIETY / DEPRESSION SCREEN
Must score a 2 or 3 on 3 out of 7 items on questions 29–35 AND Score a 4 or 5 on any of the Performance questions 36–43.
PREDOMINANTLY INATTENTIVE SUBTYPE:
✓ CRITERIA NOT MET
Must score a 2 or 3 on 6 out of 9 items on questions 1–9 AND Score a 4 or 5 on any of the Performance questions 36–43.
PREDOMINANTLY INATTENTIVE SUBTYPE:
⚠ CRITERIA MET
Must score a 2 or 3 on 6 out of 9 items on questions 1–9 AND Score a 4 or 5 on any of the Performance questions 36–43.
PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE:
✓ CRITERIA NOT MET
Must score a 2 or 3 on 6 out of 9 items on questions 10–18 AND Score a 4 or 5 on any of the Performance questions 36–43.
PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE:
⚠ CRITERIA MET
Must score a 2 or 3 on 6 out of 9 items on questions 10–18 AND Score a 4 or 5 on any of the Performance questions 36–43.
ADHD COMBINED INATTENTION / HYPERACTIVITY:
✓ CRITERIA NOT MET
Requires the above criteria on both inattention and hyperactivity / impulsivity.
ADHD COMBINED INATTENTION / HYPERACTIVITY:
⚠ CRITERIA MET
Requires the above criteria on both inattention and hyperactivity / impulsivity.
OPPOSITIONAL-DEFIANT / CONDUCT DISORDER SCREEN:
✓ CRITERIA NOT MET
Must score a 2 or 3 on 3 out of 10 items on questions 19–28 AND Score a 4 or 5 on any of the Performance questions 36–43.
OPPOSITIONAL-DEFIANT / CONDUCT DISORDER SCREEN:
⚠ CRITERIA MET
Must score a 2 or 3 on 3 out of 10 items on questions 19–28 AND Score a 4 or 5 on any of the Performance questions 36–43.
ANXIETY / DEPRESSION SCREEN:
✓ CRITERIA NOT MET
Must score a 2 or 3 on 3 out of 7 items on questions 29–35 AND Score a 4 or 5 on any of the Performance questions 36–43.
ANXIETY / DEPRESSION SCREEN:
⚠ CRITERIA MET
Must score a 2 or 3 on 3 out of 7 items on questions 29–35 AND Score a 4 or 5 on any of the Performance questions 36–43.
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