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Dear Teacher,
Please complete the form above and return to:
Dr ___________________
Sydney Developmental Clinic, Level 6, 30 Carrington Street, Sydney. NSW 2000, or fax to: (02) 9276 6101
Child’s Name: _____________________________ Date completed: ____/____/____
Teacher’s Name: _______________________________
How long has the child been in your class? __________________________________
Compared to other pupils of the same age, how applicable are the following items (0-26)
Please circle the appropriate response.
0 = Not at all 1 = Just a little/sometimes 2 = Pretty much/often 3 = Very much/ often
1) Actively defies or refuses to comply with adults’ requests or rules.
2) Argues with you, his teacher.
0 1 2 3
0 1 2 3
0 1 2 3 3) Avoids, dislikes or is reluctant to engage in tasks that require prolonged concentration (e.g. written work).
4) Blames others for his/her own mistakes or misbehaviour.
5) Blurts out answers to questions before they have been completed.
6) Deliberately annoys people.
7) Does not seem to listen when spoken to directly.
8) Fails to give close attention to details in schoolwork, work or other activities.
9) Fidgets with hands or feet or squirms in seat.
10) Has difficulty awaiting his/her turn.
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
11) Has difficulty keeping attention on work or games.
12) Has difficulty organising tasks and activities.
13) Has difficulty playing or engaging in leisure activities quietly.
14) Has trouble following through on instructions and fails to finish school work, chores or
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3 duties.
15) Interrupts or intrudes on others (e.g. butts into conversations or games).
16) Is “on the go” or acts as if “driven by a motor”.
17) Is angry and resentful.
18) Is easily distracted by external stimuli (e.g. noise or conversation).
19) Is forgetful in daily activities.
20) Is spiteful or vindictive.
21) Is touchy or easily annoyed by others.
22) Leaves seat in classroom or other situations in which remaining seated is expected.
23) Loses his/her temper or throws tantrums when he/she does not get his/her own way.
24) Loses things necessary for tasks or activities at school (e.g. pencils, books).
25) Often talks excessively.
26) Runs about or climbs excessively in situations where it is inappropriate.
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
© SDC, 2005