Vanderbilt Assessment Scale/School Report (VAS/SR)

Child's Name *

Today's Date(mm/dd/yyyy) * +

Grade Level of Student *

Your Name and Position (Teacher's Name) *

School District *

School Building *

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 the evaluation based on a time when the child was:

on medication

not on medication

unknown

Symptoms *

	Never (0)	Rarely (1)	Often (2)	Very Often (3)
1. Fails to give attention to details or makes careless mistakes in schoolwork	Never (0)	Rarely (1)	Often (2)	Very Often (3)
2. Has difficulty sustaining attention to tasks or activities	Never (0)	Rarely (1)	Often (2)	Very Often (3)
3. Does not seem to listen when spoken to directly	Never (0)	Rarely (1)	Often (2)	Very Often (3)
4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand)	Never (0)	Rarely (1)	Often (2)	Very Often (3)
5.Has difficulty organizing tasks and activities	Never (0)	Rarely (1)	Often (2)	Very Often (3)
6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort	Never (0)	Rarely (1)	Often (2)	Very Often (3)
7. Loses things necessary for tasks or activities (school assignments, pencils, or books)	Never (0)	Rarely (1)	Often (2)	Very Often (3)
8. Is easily distracted by extraneous stimuli	Never (0)	Rarely (1)	Often (2)	Very Often (3)
9. Is forgetful in daily living activities	Never (0)	Rarely (1)	Often (2)	Very Often (3)
10. Fidgets with hands or squirms in seat	Never (0)	Rarely (1)	Often (2)	Very Often (3)
11. Leaves seat in classroom or in other situations in which remaining seated is expected	Never (0)	Rarely (1)	Often (2)	Very Often (3)
12. Runs about or climbs excessively in situations in which remaining seated is expected	Never (0)	Rarely (1)	Often (2)	Very Often (3)
13. Has difficulty playing or engaging in leisure activities quietly	Never (0)	Rarely (1)	Often (2)	Very Often (3)
14. Is “on the go” or often acts as if “driven by a motor”	Never (0)	Rarely (1)	Often (2)	Very Often (3)
15. Talks excessively	Never (0)	Rarely (1)	Often (2)	Very Often (3)
16. Blurts out answers before questions have been completed	Never (0)	Rarely (1)	Often (2)	Very Often (3)
17. Has difficulty waiting in line	Never (0)	Rarely (1)	Often (2)	Very Often (3)
18. Interrupts or intrudes on others (e.g. butts into conversations/games)	Never (0)	Rarely (1)	Often (2)	Very Often (3)
19. Loses temper	Never (0)	Rarely (1)	Often (2)	Very Often (3)
20. Actively defies and refuses to comply with adult’s requests or rules	Never (0)	Rarely (1)	Often (2)	Very Often (3)
21. Is angry or resentful	Never (0)	Rarely (1)	Often (2)	Very Often (3)
22. Is spiteful or vindictive	Never (0)	Rarely (1)	Often (2)	Very Often (3)
23. Bullies, threatens, or intimidates others	Never (0)	Rarely (1)	Often (2)	Very Often (3)
24. Initiates physical fights	Never (0)	Rarely (1)	Often (2)	Very Often (3)
25. Lies to obtain goods for favors or to avoid obligations (e.g. “cons” others)	Never (0)	Rarely (1)	Often (2)	Very Often (3)
26. Is physically cruel to people	Never (0)	Rarely (1)	Often (2)	Very Often (3)
27. Has stolen items of little to no value	Never (0)	Rarely (1)	Often (2)	Very Often (3)
28. Deliberately destroys others’ property	Never (0)	Rarely (1)	Often (2)	Very Often (3)
29. Is fearful, anxious, or worried	Never (0)	Rarely (1)	Often (2)	Very Often (3)
30. Is self-conscious or easily embarrassed	Never (0)	Rarely (1)	Often (2)	Very Often (3)
31. Is afraid to try new things for fear of making mistakes	Never (0)	Rarely (1)	Often (2)	Very Often (3)
32.Feels worthless or inferior	Never (0)	Rarely (1)	Often (2)	Very Often (3)
33. Blames self for problems; feels guilty	Never (0)	Rarely (1)	Often (2)	Very Often (3)
34. Feels lonely, unwanted, or unloved; complains that "no one loves them."	Never (0)	Rarely (1)	Often (2)	Very Often (3)
35. Is sad, unhappy, or depressed	Never (0)	Rarely (1)	Often (2)	Very Often (3)

*

	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)	N/A or Unknown
36. Reading	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)	N/A or Unknown
37. Mathmatics	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)	N/A or Unknown
38. Written expression	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)	N/A or Unknown
39. Relationship with Peers	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)	N/A or Unknown
40. Following Directions	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)	N/A or Unknown
41. Disrupting Class	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)	N/A or Unknown
42. Assignment Completion	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)	N/A or Unknown
43. Organizational Skills	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)	N/A or Unknown

1. Does the student receive academic/behavioral support through an IEP, behavior plan, or 504 Plan? If yes, has the student made progress towards meeting academic and/or behavioral goals?

2. Please provide any additional information or comments about the above questions:

Center Associates

3809 South Center St.

Marshalltown, IA 50158