Child's first name _____________________________ Last name _______________________________________________

Teacher's first name ___________________Last name___________________________________ Date________________

Teacher: Please check the box that best describes this child's school behavior over the past 6 months.

		Never or rarely	Sometimes	Often	Very Often
	1. Fails to give close attention to details or makes careless mistakes in schoolwork.
	2. Fidgets with hands or feet or squirms in seat.
	3. Loses temper.
	4. Has difficulty sustaining attention in tasks or play activities.
	5. Leaves seat in classroom or in other situations in which remaining seated is expected.
	6. Argues with adults rules.
	7. Does not seem to listen when spoken to directly.
	8. Runs about or climbs excessively in situations in which it is inappropriate.
	9. Actively defies or refuses to comply with adult’s requests or rules.
	10. Does not follow through on instructions and fails to finish work.
	11. Has difficulty playing or engaging in leisure activities quietly.
	12. Deliberately annoys people.
	13. Has difficulty organizing tasks and activities.
	14. Is “on the go” or acts as if “driven by a motor.”
	15. Blames others for his or her mistakes or misbehavior.
	16. Avoids tasks, such as schoolwork, that require sustained mental effort.
	17. Talks excessively.
	18. Touchy or easily annoyed by others.
	19. Loses things necessary for tasks or activities.
	20. Blurts out answers before questions have been completed.
	21. Angry or resentful.
	22. Is easily distracted.
	23. Has difficulty awaiting turn.
	24. Acts spiteful or vindictive.
	25. Is forgetful in daily activities.
	26. Interrupts or intrudes on others.