Vanderbilt Assessment Scale-Parent Informant #6175

Vanderbilt.

Name of child:___________________ Gender:______ Age:___ Grade:_____Date: ____________

Completed by: _________________________ Parent's Phone Number: ______________________

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form please think about your child's behavior in the past 6 months.

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

		Never	Occasionally	Often	Very Often
Symptoms		Never	Occasionally	Often	Very Often
1.	Does not pay close attention to details or makes careless mistakes with, for example, homework	0	1	2	3
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 on instructions and fails to finish schoolwork, chores, or duties	0	1	2	3
5.	Has difficulty organizing tasks and activities	0	1	2	3

..	Performance Academic Performance	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
48.	Reading	1	2	3	4	5
49.	Mathematics	1	2	3	4	5
50.	Written expression	1	2	3	4	5
.	*Classroom Behavioral Performance*	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
51.	Relationship with peers	1	2	3	4	5

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