Snap Iv Form – Fill Out and Use This PDF

Name:_______________________________________________________________________

Gender:_________ Age:_________ Grade:_________

Ethnicity (circle one which best applies):

African-American Asian

Caucasian Hispanic

Other_______________________________________

Completed by:_____________________________________________

Type of Class:____________________ Class size:_______________________

For each item, check the column which best describes this child:

Not At

Just A

Quite

Very

All

Little

A Bit

Much

1.

Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks

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2.

Often has difficulty sustaining attention in tasks or play activities

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3.

Often does not seem to listen when spoken to directly

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4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties

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5.

Often has difficulty organizing tasks and activities

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6.

Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort

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7.

Often loses things necessary for activities (e.g., toys, school assignments, pencils, or books)

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8.

Often is distracted by extraneous stimuli

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9.

Often is forgetful in daily activities

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10.

Often has difficulty maintaining alertness, orienting to requests, or executing directions

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11.

Often fidgets with hands or feet or squirms in seat

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12.

Often leaves seat in classroom or in other situations in which remaining seated is expected

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13.

Often runs about or climbs excessively in situations in which it is inappropriate

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14.

Often has difficulty playing or engaging in leisure activities quietly

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15.

Often is “on the go” or often acts as if

“driven by a motor”

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16.

Often talks excessively

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17.

Often blurts out answers before questions have been completed

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18.

Often has difficulty awaiting turn

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19.

Often interrupts or intrudes on others (e.g., butts into conversations/games)

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20.

Often has difficulty sitting still, being quiet, or inhibiting impulses in the classroom or at home

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21.

Often loses temper

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22.

Often argues with adults

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23.

Often actively defies or refuses adult requests or rules

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24.

Often deliberately does things that annoy other people

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25.

Often blames others for his or her mistakes or misbehavior

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26.

Often touchy or easily annoyed by others

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27

Often is angry and resentful

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28.

Often is spiteful or vindictive

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29.

Often is quarrelsome

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30.

Often is negative, defiant, disobedient, or hostile toward authority figures

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31.

Often makes noises (e.g., humming or odd sounds)

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32.

Often is excitable, impulsive

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33.

Often cries easily

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34.

Often is uncooperative

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35.

Often acts “smart”

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36.

Often is restless or overactive

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37.

Often disturbs other children

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38.

Often changes mood quickly and drastically

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39.

Often easily frustrated if demand are not met immediately

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40.

Often teases other children and interferes with their activities

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Check the column which best describes this child:

Not At

Just A

Quite

Very

All

Little

A Bit

Much

41.

Often is aggressive to other children (e.g., picks fights or bullies)

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42.

Often is destructive with property of others (e.g., vandalism)

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43.

Often is deceitful (e.g., steals, lies, forges, copies the work of others, or “cons” others)

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44.

Often and seriously violates rules (e.g., is truant, runs away, or completely ignores class rules)

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45.

Has persistent pattern of violating the basic rights of others or major societal norms

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46.

Has episodes of failure to resist aggressive impulses (to assault others or to destroy property)

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47.

Has motor or verbal tics (sudden, rapid, recurrent, nonrhythmic motor or verbal activity)

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48.

Has repetitive motor behavior (e.g., hand waving, body rocking, or picking at skin)

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49.

Has obsessions (persistent and intrusive inappropriate ideas, thoughts, or impulses)

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50.

Has compulsions (repetitive behaviors or mental acts to reduce anxiety or distress)

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51.

Often is restless or seems keyed up or on edge

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52.

Often is easily fatigued

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53.

Often has difficulty concentrating (mind goes blank)

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54.

Often is irritable

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55.

Often has muscle tension

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56.

Often has excessive anxiety and worry (e.g., apprehensive expectation)

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57.

Often has daytime sleepiness (unintended sleeping in inappropriate situations)

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58.

Often has excessive emotionality and attention-seeking behavior

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59.

Often has need for undue admiration, grandiose behavior, or lack of empathy

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60.

Often has instability in relationships with others, reactive mood, and impulsivity

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61

Sometimes for at least a week has inflated self esteem or grandiosity

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62.

Sometimes for at least a week is more talkative than usual or seems pressured to keep talking

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63.

Sometimes for at least a week has flight of ideas or says that thoughts are racing

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64.

Sometimes for at least a week has elevated, expansive or euphoric mood

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65.

Sometimes for at least a week is excessively involved in pleasurable but risky activities

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66.

Sometimes for at least 2 weeks has depressed mood (sad, hopeless, discouraged)

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67.

Sometimes for at least 2 weeks has irritable or cranky mood (not just when frustrated)

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68.

Sometimes for at least 2 weeks has markedly diminished interest or pleasure in most activities

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69.

Sometimes for at least 2 weeks has psychomotor agitation (even more active than usual)

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70.

Sometimes for at least 2 weeks has psychomotor retardation (slowed down in most activities)

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71.

Sometimes for at least 2 weeks is fatigued or has loss of energy

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72.

Sometimes for at least 2 weeks has feelings of worthlessness or excessive, inappropriate guilt

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73.

Sometimes for at least 2 weeks has diminished ability to think or concentrate

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74.

Chronic low self-esteem most of the time for at least a year

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75.

Chronic poor concentration or difficulty making decisions most of the time for at least a year

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76.

Chronic feelings of hopelessness most of the time for at least a year

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77.

Currently is hypervigilant (overly watchful or alert) or has exaggerated startle response

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78.

Currently is irritable, has anger outbursts, or has difficulty concentrating

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79.

Currently has an emotional (e.g., nervous, worried, hopeless, tearful) response to stress

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80.

Currently has a behavioral (e.g., fighting, vandalism, truancy) response to stress

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81.

Has difficulty getting started on classroom assignments

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82.

Has difficulty staying on task for an entire classroom period

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83.

Has problems in completion of work on classroom assignments

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84.

Has problems in accuracy or neatness of written work in the classroom

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85.

Has difficulty attending to a group classroom activity or discussion

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86.

Has difficulty making transitions to the next topic or classroom period

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87.

Has problems in interactions with peers in the classroom

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88.

Has problems in interactions with staff (teacher or aide)

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89.

Has difficulty remaining quiet according to classroom rules

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90.

Has difficulty staying seated according to classroom rules

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