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NICHQ Vanderbilt Assessment Scale—PARENT Informant

Today’s Date: ___________ Child’s Name: _____________________________________________ Date of Birth: _______________ Parent’s Name: _____________________________________________ 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 behaviors in the past 6 months. Is this evaluation based on a time when the child was on medication was not on medication Occasionally 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Often 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 not sure? Very Often 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Symptoms Never 1. Does not pay attention to details or makes careless mistakes 0 with, for example, homework 2. Has difficulty keeping attention to what needs to be done 0 3. Does not seem to listen when spoken to directly 0 4. Does not follow through when given directions and fails to finish activities 0 (not due to refusal or failure to understand) 5. Has difficulty organizing tasks and activities 0 6. Avoids, dislikes, or does not want to start tasks that require ongoing 0 mental effort 7. Loses things necessary for tasks or activities (toys, assignments, pencils, 0 or books) 8. Is easily distracted by noises or other stimuli 0 9. Is forgetful in daily activities 0 10. Fidgets with hands or feet or squirms in seat 0 11. Leaves seat when remaining seated is expected 0 12. Runs about or climbs too much when remaining seated is expected 0 13. Has difficulty playing or beginning quiet play activities 0 14. Is “on the go” or often acts as if “driven by a motor” 0 15. Talks too much 0 16. Blurts out answers before questions have been completed 0 17. Has difficulty

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