Child And Adolescent Screening Checklist For Behavior Vanderbilt Assessment Scale Template
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4PHARR-SAN JUAN-ALAMO INDEPENDENT SCHOOL DISTRICT
CHILD AND ADOLESCENT SCREENING CHECKLIST FOR BEHAVIOR
VANDERBILT ASSESSMENT SCALE – PARENT INFORMATION
Name of child:_____________________ Gender: ______ Age:___ Grade: ______ Date: _____________
Completed by: _____________________________ Parent's Phone Number: ______________________
Directions: Each rating should be considered in the context of what is appropriate for the age of your child.
When completing this form please think about your child's behavior in the past 6 months.
Is this evaluation based on a time the child __ was on medication __ was not on medication __ not sure?
Very
Symptoms
Never Occasionally Often
Often
Does not pay close attention to details or makes careless mistakes with, for example,
1.
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homework
2.
Has difficulty keeping attention to what needs to be done
0
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3.
Does not seem to listen when spoken to directly
0
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4.
Does not follow through on instructions and fails to finish schoolwork, chores, or duties
0
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5.
Has difficulty organizing tasks and activities
0
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3
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g.,
6.
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schoolwork or homework)
Loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books,
7.
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or tools)
8.
Is distracted by extraneous stimuli
0
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9.
Is forgetful in daily activities
0
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10. Fidgets with hands or feet or squirms in seat
0
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11. Leaves seat in classroom or in other situations in which remaining seated is expected
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12. Runs about or climbs excessively in situations in which remaining seated is expected
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13. Has difficulty playing or engaging in leisure activities quietly
0
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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 (eg, butts into conversations/games)
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Continue with page 2
Vanderbilt Assessment Scale - Parent Information
page 1
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