Vanderbilt Assessment Form – Fill Out and Use This PDF

The Vanderbilt Assessment Form is a tool developed for evaluating the behavior and performance of children in educational settings, primarily focusing on aspects related to attention, hyperactivity, and other behavioral indicators that could suggest attention deficit hyperactivity disorder (ADHD) or related conditions. It provides a structured way for teachers to report observations of a child’s behavior, academic performance, and any observed side effects of medication. The form encourages detailed reporting on a range of behaviors and academic skills, making it easier to identify areas where a child might need support or further evaluation. To better understand a child’s behavior and academic performance or to initiate further assessments, clicking the button below to fill out the Vanderbilt Assessment Form is recommended.

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Vanderbilt Assessment Form PDF Details

The Vanderbilt Assessment form serves as a critical tool for tracking a variety of behavioral and academic performance indicators in children, particularly focusing on symptoms related to Attention Deficit Hyperactivity Disorder (ADHD) and its management over time. Administered by teachers, this evaluation offers a comprehensive look at a child's behavior, organizing symptoms into two primary categories: those that hinder attention and focus, and those that implicate hyperactivity and impulsivity. Additionally, it assesses academic performance across several key areas, including reading, mathematics, and written expression, alongside social interactions and classroom behavior. Teachers are asked to rate the frequency of eighteen specific behaviors, ranging from a lack of attention to detail to excessive fidgeting or talking. The form is thoughtfully designed to consider how these behaviors compare with what is typically expected for a child’s age, and it requires teachers to reflect on the child's behavior over a specific period. Furthermore, the Vanderbilt Assessment includes a section on possible medication side effects, acknowledging the importance of monitoring the holistic impact of any treatment plan. Originally developed by Mark L. Wolraich, MD, and adapted by reputable institutions, this assessment tool underscores the importance of individualized evaluation and the variability of treatment effectiveness, thereby guiding more tailored and effective interventions for each child. Notably, the disclaimer emphasizes that the recommendations made do not indicate an exclusive course of treatment, highlighting the personalized approach needed in addressing children's healthcare improvement.

Question	Answer
Form Name	Vanderbilt Assessment Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	vanderbilt assessment teacher, vanderbilt form, vanderbilt forms, vanderbilt teacher assessment

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D6	NICHQ Vanderbilt Assessment Follow-up—TEACHER Informant

TeacherÕs Name: _______________________________ Class Time: ___________________ Class Name/Period: _______________

TodayÕs Date: ___________ ChildÕs Name: _______________________________ Grade Level: ______________________________

Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the last assessment scale was filled out. Please indicate the number of weeks or months you have been able to evaluate the behaviors: ___________.

Is this evaluation based on a time when the child		■ was on medication ■ was not on medication ■ not sure?

Symptoms			Never	Occasionally	Often	Very Often

1.	Does not pay attention to details or makes careless mistakes with,		0	1	2	3
	for example, homework

2.	Has difficulty keeping attention to what needs to be done		0	1	2	3

3.	Does not seem to listen when spoken to directly		0	1	2	3

4.	Does not follow through when given directions and fails to finish		0	1	2	3
	activities (not due to refusal or failure to understand)

5.	Has difficulty organizing tasks and activities		0	1	2	3

6.	Avoids, dislikes, or does not want to start tasks that require ongoing		0	1	2	3
	mental effort

7.	Loses things necessary for tasks or activities (toys, assignments,		0	1	2	3
	pencils, or books)

8.	Is easily distracted by noises or other stimuli		0	1	2	3

9.	Is forgetful in daily activities		0	1	2	3

10.	Fidgets with hands or feet or squirms in seat		0	1	2	3

11.	Leaves seat when remaining seated is expected		0	1	2	3

12.	Runs about or climbs too much when remaining seated is expected		0	1	2	3

13.	Has difficulty playing or beginning quiet play activities		0	1	2	3

14.	Is Òon the goÓ or often acts as if Òdriven by a motorÓ		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

17.	Has difficulty waiting his or her turn		0	1	2	3
18.	Interrupts or intrudes in on othersÕ conversations and/or activities		0	1	2	3


					Somewhat
			Above		of a
Performance		Excellent	Average	Average	Problem Problematic
19.	Reading	1	2	3	4	5

20.	Mathematics	1	2	3	4	5

21.	Written expression	1	2	3	4	5

22.	Relationship with peers	1	2	3	4	5

23.	Following direction	1	2	3	4	5

24.	Disrupting class	1	2	3	4	5

25.	Assignment completion	1	2	3	4	5

26.	Organizational skills	1	2	3	4	5

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circum- stances, may be appropriate.

Copyright © 2005 American Academy of Pediatrics, University of North Carolina at Chapel Hill for its North Carolina Center for ChildrenÕs Healthcare Improvement, and National Initiative for ChildrenÕs Healthcare Quality

Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD.

Revised - 0303

D6 NICHQ Vanderbilt Assessment Follow-up—TEACHER Informant, continued

TeacherÕs Name: _______________________________ Class Time: ___________________ Class Name/Period: ________________

TodayÕs Date: ___________ ChildÕs Name: _______________________________ Grade Level: ______________________________

Side Effects: Has the child experienced any of the following side	Are these side effects currently a problem?

effects or problems in the past week?	None	Mild	Moderate	Severe

Headache
Stomachache

Change of appetiteÑexplain below

Trouble sleeping

Irritability in the late morning, late afternoon, or eveningÑexplain below

Socially withdrawnÑdecreased interaction with others

Extreme sadness or unusual crying

Dull, tired, listless behavior

Tremors/feeling shaky
Repetitive movements, tics, jerking, twitching, eye blinkingÑexplain below

Picking at skin or fingers, nail biting, lip or cheek chewingÑexplain below

Sees or hears things that arenÕt there
Explain/Comments:

For Office Use Only

Total Symptom Score for questions 1Ð18: ____________________________________

Average Performance Score: ______________________________________________

Please return this form to: ________________________________________________________________________________________________________

Mailing address:__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Fax number: __________________________________________________________________________________________________________________________________________________________

Adapted from the Pittsburgh side effects scale, developed by William E. Pelham, Jr, PhD. Available for downloading at no cost in expanded format at http://wings.buffalo.edu/adhd

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