Teacher Questionnaire

Dear Educator,

As a part of this student’s evaluation process, the following questionnaire is extremely helpful in providing me an understanding of what you are noticing at school. At your earliest convenience, please complete and return this form to me at drbaker@bakernlc.com. Thank you!

Sign in to Google to save your progress. Learn more
Student First and Last Name *
Your Name: *
Grade and Subject(s) you teach: *
How long have you known this student: *
Please describe this student's unique strengths: *
Please describe this student's unique weaknesses, if any: *
Please describe any specific academic/learning difficulties or obstacles this student faces or may face: *
If applicable, please estimate this students' grades and proficiency (in area(s) you teach): *

Do you have any concerns with the speed and efficiency in which this student completes tasks? If yes, please explain:

 *
How does this student do with learning new information? *

If applicable, does this student have difficulty understanding abstract concepts? If yes, please explain:

 *

Does this student have difficulty focusing or paying attention? If yes, please explain:

 *

if applicable, does this student have difficulty keeping track of assignments / materials? If yes, please explain:

 *
Please describe how this student gets along with other students or staff at the school *
Does this student exhibit any behavioral problems at school? If yes, please explain: *
Do you have any concerns for this student's emotional functioning? If yes, please explain: *

If applicable, please describe any attempts that have been made so far to address any identified difficulties (e.g. RTI, IEP, 504, or other classroom interventions or accommodations, etc.):

 *
Please use the space below for any additional information you would like to share about this student: *
Can I contact you for additional information if needed (with signed consent)? *
Email Address:
Phone Number:
NICHQ Vanderbilt Assessment Scale

Instructions: 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 how often the behavior occurs: Never, Occasionally, Often, and Very Often.

***Please attempt to answer every question below, but if it is not applicable then select "Never"

Fails to give attention to details or makes careless mistakes in schoolwork *
Has difficulty sustaining attention to tasks or activities *
Does not seem to listen when spoken to directly *
Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand) *
Has difficulty organizing tasks and activities *
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort *
Loses things necessary for tasks or activities (school assignments, pencils, or books) *
Is easily distracted by extraneous stimuli *
Is forgetful in daily activities *
Fidgets with hands or feet or squirms in seat *
Leaves seat in classroom or in other situations in which remaining seated is expected *
Runs about or climbs excessively in situations in which remaining seated is expected *
Has difficulty playing or engaging in leisure activities quietly *
Is "on the go" or often act as if "driven by a motor" *
Talks excessively *
Blurts out answers before questions have been completed *
Has difficulty waiting in line *
Interrupts or intrudes on others (e.g., butts into conversation/games) *
Loses temper *
Actively defies or refuses to comply with adult requests or rules *
Is angry or resentful *
Is spiteful and vindictive *
Bullies, threatens, or intimidates others *
Initiates physical fights *
Lies to obtain goods for favors or to avoid obligations (i.e., “cons” others) *
Is physically cruel to people *
Has stolen items of nontrivial value *
Deliberately destroys others' property *
Is fearful, anxious, or worried *
Is self-conscious or easily embarrassed *
Is afraid to try new things for fear of making mistakes *
Feels worthless or inferior *
Blames self for problems; feels guilty *
Feels lonely, unwanted, or unloved; complains that "no one loves him or her" *
Is sad, unhappy, or depressed *
Performance
Academic Performance
Mathematics
Clear selection
Written Expression
Clear selection
Spelling
Clear selection
Reading Fluency
Clear selection
Reading Comprehension
Clear selection
Performance
Classroom Behavioral Performance
Relationship with Peers
Clear selection
Following Directions
Clear selection
Disrupting class
Clear selection
Assignment completion
Clear selection
Organizational skills
Clear selection
Any additional comments
Thank you
Thank you for completing our form. Your answers will be thoughtfully looked over.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Baker Neuropsychology and Learning Center. Report Abuse
Google Forms