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| Child's Name____________________________________ | Age_____________ | Gender_____________ |
| School________________________________________ | Grade___________ | Date_______________ |
| Teacher Report Form | Never | Some- times |
Often | Very Often |
| 1. Fails to give close attention to details or makes careless mistakes | ___ | ___ | ___ | ___ |
| 2. Has difficulty paying attention to tasks or play activities | ___ | ___ | ___ | ___ |
| 3. Does not seem to listen when spoken to directly | ___ | ___ | ___ | ___ |
| 4. Has difficulty following through on instructions and fails to finish things | ___ | ___ | ___ | ___ |
| 5. Has difficulty organizing tasks and activities | ___ | ___ | ___ | ___ |
| 6. Avoids doing tasks that require a lot of mental effort (schoolwork, homework, etc.) | ___ | ___ | ___ | ___ |
| 7. Loses things necessary for activities | ___ | ___ | ___ | ___ |
| 8. Is easily distracted by other things going on | ___ | ___ | ___ | ___ |
| 9. Is forgetful in daily activities | ___ | ___ | ___ | ___ |
| 10. Fidgets with hands or feet; squirms in seat | ___ | ___ | ___ | ___ |
| 11. Has difficulty remaining seated when asked to do so | ___ | ___ | ___ | ___ |
| 12. Runs about or climbs on things when asked not to | ___ | ___ | ___ | ___ |
| 13. Has difficulty playing quietly | ___ | ___ | ___ | ___ |
| 14. Is "on the go" or acts as if "driven by a motor" | ___ | ___ | ___ | ___ |
| 15. Talks excessively | ___ | ___ | ___ | ___ |
| 16. Blurts outo answers to questions before they have been completed | ___ | ___ | ___ | ___ |
| 17. Has difficulty awaiting turn in group activities | ___ | ___ | ___ | ___ |
| 18. Interrupts other people or butts into other children's activities | ___ | ___ | ___ | ___ |
| 19. Loses temper | ___ | ___ | ___ | ___ |
| 20. Argues with adults | ___ | ___ | ___ | ___ |
| 21. Defies or refuses what you tell him/her to do | ___ | ___ | ___ | ___ |
| 22. Does things to deliberately annoy others | ___ | ___ | ___ | ___ |
| 23. Blames others for own behavior or mistakes | ___ | ___ | ___ | ___ |
| 24. Is touchy or easily annoyed by others | ___ | ___ | ___ | ___ |
| 25. Is angry or resentful | ___ | ___ | ___ | ___ |
| 26. Takes anger out on others or tries to get even | ___ | ___ | ___ | ___ |