Snap Iv Form PDF Details

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QuestionAnswer
Form NameSnap Iv Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessnap iv forms, hypervigilant, nonrhythmic, Swanson

Form Preview Example

The SNAP-IV Teacher and Parent Rating Scale

James M. Swanson, Ph.D., University of California, Irvine, CA 92715

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

______

______

______

______

2.

Often has difficulty sustaining attention in tasks or play activities

 

______

______

______

______

3.

Often does not seem to listen when spoken to directly

 

______

______

______

______

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

______

______

______

______

5.

Often has difficulty organizing tasks and activities

 

______

______

______

______

6.

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

______

______

______

______

7.

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

______

______

______

______

8.

Often is distracted by extraneous stimuli

 

______

______

______

______

9.

Often is forgetful in daily activities

 

 

______

______

______

______

10.

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

______

______

______

______

11.

Often fidgets with hands or feet or squirms in seat

 

______

______

______

______

12.

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

______

______

______

______

13.

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

______

______

______

______

14.

Often has difficulty playing or engaging in leisure activities quietly

 

______

______

______

______

15.

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

“driven by a motor”

 

______

______

______

______

16.

Often talks excessively

 

 

______

______

______

______

17.

Often blurts out answers before questions have been completed

 

______

______

______

______

18.

Often has difficulty awaiting turn

 

 

______

______

______

______

19.

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

______

______

______

______

20.

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

______

______

______

______

21.

Often loses temper

 

 

______

______

______

______

22.

Often argues with adults

 

 

______

______

______

______

23.

Often actively defies or refuses adult requests or rules

 

______

______

______

______

24.

Often deliberately does things that annoy other people

 

______

______

______

______

25.

Often blames others for his or her mistakes or misbehavior

 

______

______

______

______

26.

Often touchy or easily annoyed by others

 

______

______

______

______

27

Often is angry and resentful

 

 

______

______

______

______

28.

Often is spiteful or vindictive

 

 

______

______

______

______

29.

Often is quarrelsome

 

 

______

______

______

______

30.

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

______

______

______

______

31.

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

 

______

______

______

______

32.

Often is excitable, impulsive

 

 

______

______

______

______

33.

Often cries easily

 

 

______

______

______

______

34.

Often is uncooperative

 

 

______

______

______

______

35.

Often acts “smart”

 

 

______

______

______

______

36.

Often is restless or overactive

 

 

______

______

______

______

37.

Often disturbs other children

 

 

______

______

______

______

38.

Often changes mood quickly and drastically

 

______

______

______

______

39.

Often easily frustrated if demand are not met immediately

 

______

______

______

______

40.

Often teases other children and interferes with their activities

 

______

______

______

______

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)

______

______

______

______

42.

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

______

______

______

______

43.

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

______

______

______

______

44.

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

______

______

______

______

45.

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

______

______

______

______

46.

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

______

______

______

______

47.

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

______

______

______

______

48.

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

______

______

______

______

49.

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

______

______

______

______

50.

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

______

______

______

______

51.

Often is restless or seems keyed up or on edge

______

______

______

______

52.

Often is easily fatigued

______

______

______

______

53.

Often has difficulty concentrating (mind goes blank)

______

______

______

______

54.

Often is irritable

______

______

______

______

55.

Often has muscle tension

______

______

______

______

56.

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

______

______

______

______

57.

Often has daytime sleepiness (unintended sleeping in inappropriate situations)

______

______

______

______

58.

Often has excessive emotionality and attention-seeking behavior

______

______

______

______

59.

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

______

______

______

______

60.

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

______

______

______

______

61

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

______

______

______

______

62.

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

______

______

______

______

63.

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

______

______

______

______

64.

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

______

______

______

______

65.

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

______

______

______

______

66.

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

______

______

______

______

67.

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

______

______

______

______

68.

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

______

______

______

______

69.

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

______

______

______

______

70.

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

______

______

______

______

71.

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

______

______

______

______

72.

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

______

______

______

______

73.

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

______

______

______

______

74.

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

______

______

______

______

75.

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

______

______

______

______

76.

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

______

______

______

______

77.

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

______

______

______

______

78.

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

______

______

______

______

79.

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

______

______

______

______

80.

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

______

______

______

______

81.

Has difficulty getting started on classroom assignments

______

______

______

______

82.

Has difficulty staying on task for an entire classroom period

______

______

______

______

83.

Has problems in completion of work on classroom assignments

______

______

______

______

84.

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

______

______

______

______

85.

Has difficulty attending to a group classroom activity or discussion

______

______

______

______

86.

Has difficulty making transitions to the next topic or classroom period

______

______

______

______

87.

Has problems in interactions with peers in the classroom

______

______

______

______

88.

Has problems in interactions with staff (teacher or aide)

______

______

______

______

89.

Has difficulty remaining quiet according to classroom rules

______

______

______

______

90.

Has difficulty staying seated according to classroom rules

______

______

______

______

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