Teacher Vanderbilt Questionnaire Vanderbilt for Teachers Vanderbilt (for Teachers) Email to receive your copy (Optional) Confirm Email to receive your copy (Optional) Enter a confirmation email address. Today's Date * (MM/DD/YYYY) Child's Name * Grade Level * Teacher's Name * Months/Weeks Observed Class Time Class Name/Period Medication Checkbox On Medication Not on Medication Not Sure About Medication Questions 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 instructions and fails to finish schoolwork 0 (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 sustained mental effort Never Occasionally Often Very Often 7. Loses things necessary for tasks or activities (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 ofen 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 (eg, butts into conversations/games) Never Occasionally Often Very Often 19. Loses temper Never Occasionally Often Very Often 20. Actively defies or refuses to go along 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 (eg, “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 or her” Never Occasionally Often Very Often 35. Is sad, unhappy, or depressed Never Occasionally Often Very Often 36. Academic Performance: Reading Excellent Above Average Average Somewhat a Problem Problematic 37. Academic Performance: Mathematics Excellent Above Average Average Somewhat a Problem Problematic 38. Academic Performance: Written expression Excellent Above Average Average Somewhat a Problem 39. Classroom Behavioral Performance: Relationship with peers Excellent Above Average Average Somewhat a Problem Problematic 40. Classroom Behavioral Performance: Following directions Excellent Above Average Average Somewhat a Problem Problematic 41. Classroom Behavioral Performance: Disrupting class Excellent Above Average Average Somewhat a Problem Problematic 42. Classroom Behavioral Performance: Assignment completion Excellent Above Average Average Somewhat a Problem Problematic 43. Classroom Behavioral Performance: Organizational skills Excellent Above Average Average Somewhat a Problem Problematic If you are human, leave this field blank. Submit
