Dekalb Pediatric Center
350 Winn Way
Decatur, GA  30030
(404) 508-1177
(404) 508-9640 fax

SCHOOL QUESTIONNAIRE

Student’s Name:  _________________________________________
Student’s Date of Birth: ____________________________________

Directions The above named child is being evaluated for school and behavioral problems. Please complete this form by filling in or circling the appropriate answer. If you have questions please call if you have questions.

1.	What is today’s date? ____________________
2.	What is your name? _____________________________________________________________
3.	What is your relationship (e.g., classroom teacher, English teacher, school counselor) to this child? _________________________________________________
4.	How long have you known this child? _________________________
5.	What is your daytime phone number? ____________________________________
6.	What is your daytime fax number? _______________________________________
7.	May the pediatrician’s office you contact you if additional information is needed?
Yes	®	What days of the week and times would be convenient for you? 	
			
No
8.	How long have you and/or other school professionals been concerned about this child’s behaviors and/or academic functioning?  _____________
9.	What concerns do you and/or other school professionals have about this student?

10. Has this child been in an Early Intervention Program	Yes	No	Don’t know		
11.  Has this child had speech, occupational or physical therapy?	Yes	No	Don’t know		
12. Has this child repeated a grade?	Yes	No	Don’t know	13. If yes, which grade(s) have been repeated?	
14. Has repeating a grade been considered? 	Yes	No	Don’t know	If yes, please describe	
15. Is there a possibility that current grade or subjects will need repeating?	Yes	No	Don’t know	If yes, please describe	
16. Has this child received any special education services in the past?	Yes	No	Don’t know	If yes, please describe	
17. Is this child currently receiving any special education services?	Yes	No	Don’t know	If yes, please describe	
18.	Do you know of any problems that the child may have experienced in the following grades?
Preschool	No	Yes 	If yes, please describe.
	
Kindergarten	No	Yes 	If yes, please describe.
	
1st grade	No	Yes 	If yes, please describe.
	
2ndgrade	No	Yes 	If yes, please describe.
	
3rd grade	No	Yes 	If yes, please describe.
	
4-5th grades	No	Yes 	If yes, please describe.
	
6-8th grades	No	Yes 	If yes, please describe.
	
9-12th grades	No	Yes 	If yes, please describe.

19.	Please list any Aptitude/Psychological or Achievement/Academic tests administered to this child. Please send copies of test results if they are available.
Name of test	Date given	Child’s grade level	Results	
a. 				
b. 				

NICHQ Vanderbilt ASSESSMENT Scale -TEACHER Informant 	Page 1
Teacher’s Name: ___________________________			Today’s Date: ______________
Child’s 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 beginning of the school year.  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   r was on medication   r was not on medication   r not sure?

SYMPTOMS
                                                                                                                                                                                                                                 Never        Occasionally         Often        Very Often
1.   Fails to give attention to details or makes careless mistakes	0	1	2	3
      in schoolwork.	

2.   Has difficulty sustaining attention to tasks or activities.	0	1	2	3

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

4.   Does not follow through on instructions and fails to finish school-	0	1	2	3
      work (not due to oppositional behavior or failure to understand).	

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

6.   Avoids, dislikes, or is reluctant to engage in tasks that require	0	1	2	3
      sustained mental effort.

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

8.   Is easily distracted by extraneous 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 in classroom or in other situations in which	0	1	2	3
      remaining seated is expected.

12. Runs about or climbs excessively in situations in which	0	1	2	3
      remaining seated is expected.

13. Has difficulty playing or engaging in leisure activities quietly.	0	1	2	3

14. Is “on the go” or often acts as if “driven by a motor.”	0	1	2	3

15. Talks excessively.	0	1	2	3

16. Blurts out answers before questions have been completed.	0	1	2	3

17. Has difficulty waiting in line.	0	1	2	3

18. Interrupts or intrudes on others (e.g., butts into conversations	0	1	2	3
      or games).

19. Loses temper.	0	1	2	3

20. Actively defies or refuses to comply with adult’s requests or rules.	0	1	2	3
      
21. Is angry or resentful.	0	1	2	3

22. Is spiteful and vindictive.	0	1	2	3

23. Bullies, threatens, or intimidates others.	0	1	2	3

NICHQ Vanderbilt ASSESSMENT Scale -TEACHER Informant 	Page 2
Teacher’s Name: ___________________________			Today’s Date: ______________
Child’s Name: ______________________________	Grade Level: __________	
                                                                                                                                                                                                                                 Never         Occasionally        Often        Very Often
24. Initiates physical fights.	0	1	2	3

25. Lies to obtain goods for favors or to avoid obligations	0	1	2	3
      (e.g., “cons” others)

26. Is physically cruel to people.	0	1	2	3

27. Has stolen items of nontrivial value.	0	1	2	3

28. Deliberately destroys others’ property.	0	1	2	3

29. Is fearful, anxious, or worried.	0	1	2	3

30. Is self-conscious or easily embarrassed.	0	1	2	3

31. Is afraid to try new things for fear of making mistakes.	0	1	2	3

32. Feels worthless or inferior.	0	1	2	3

33. Blames self for problems; feels guilty.	0	1	2	3

34. Feels lonely, unwanted, or unloved; complains that “no	0	1	2	3
      one loves him/her.”

35. Is sad, unhappy, or depressed.	0	1	2	3

 PERFORMANCE	
Academic Performance
	Problematic	Somewhat of	Average	Above	Excellent
		A Problem		Average	
36. Reading	5	4	3	2	1
37. Mathematics	5	4	3	2	1
38. Written Expression	5	4	3	2	1

Classroom Behavioral Performance
	Problematic	Somewhat of	Average	Above	Excellent
		A Problem		Average	
39. Relationship with peers	5	4	3	2	1
40. Following directions	5	4	3	2	1
41. Disrupting class	5	4	3	2	1
42. Assignment completion	5	4	3	2	1
43. Organizational skills	5	4	3	2	1

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