Vanderbilt Teacher Assessment Follow-Up
ADVERTISEMENT
1
2Vanderbilt Teacher Assessment Follow-Up
Page 1
Today’s Date: _________ Child’s Name: ________________________________________ DOB: ________
Teacher’s Name: ______________________________________ School: _______________________________________ Grade: ________
Each rating should be considered in the context of what is appropriate for the age of the child you are rating.
Is this evaluation based on a time when the child
was on medication
was not on medication
not sure
Very
SYMPTOMS
Never
Occasionally
Often
Often
1. Fails to give attention to details or makes careless mistakes in
0
1
2
3
schoolwork
2. Has difficulty sustaining attention to task 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
0
1
2
3
(not due to oppositional behavior or failure to understand)
5. Has difficulty organizing task and activities
0
1
2
3
6. Avoids, dislikes, or is reluctant to engage in tasks that require
0
1
2
3
sustained mental efforts
7. Loses things necessary for tasks or activities (school assignments,
0
1
2
3
pencils, or books)
8. Is easily distracted by extraneous stimuli
0
1
2
3
Count #
9. Is forgetful in daily activities
0
1
2
3
2s + 3s
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
0
1
2
3
seated is expected
12. Runs about or climbs too much when 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 too much
0
1
2
3
16. Blurts out answers before questions have been completed
0
1
2
3
Count #
17. Has difficulty waiting his/her turn
0
1
2
3
2s + 3s
TSS
0
1
2
3
18. Interrupts or intrudes in others’ conversations and/or activities
1-18
Above
Somewhat of
IMPAIRMENT
Excellent
Average
Problematic
Average
a Problem
A. Reading
1
2
3
4
5
B. Mathematics
1
2
3
4
5
Total #
C. Written Expression
1
2
3
4
5
4s + 5s
D. Relationship with peers
1
2
3
4
5
E. Following directions
1
2
3
4
5
F. Disrupting class
1
2
3
4
5
Count #
G. Assignment completion
1
2
3
4
5
4s + 5s
APS
H. Organizational skills
1
2
3
4
5
19-26
Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD
FAX OR MAIL COMPLETED FORM TO: (Check one office/location)
nd
(Enter practice contact information)
(Enter practice contact information – 2
office/location)
Name of Practice
Name of Practice
Street Address
Street Address
Phone Number/Fax Number
Phone Number/Fax Number
rd
th
(Enter practice contact information – 3
office/location)
(Enter practice contact information – 4
office/location)
-Please Turn Over-
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business