|
| Child's Name: |
Age: |
| Filled Out By: |
Child's Sex: ___ M ___F |
| Date: |
|
DIRECTIONS:
Below is a list of items that describes pupils. For
each item that describes the pupil, now or within the past
week, check whether the item is Not True, Somewhat or
Sometimes True, or Very or Often True. Please check
all items as well as you can, even if some do not seem to
apply to this pupil. |
|
|
|
Not
True |
Somewhat or Sometimes True |
Very or Often True |
| 1. |
Fails to finish things he/she starts
|
[ ] |
[ ] |
[ ] |
| 2. |
Can't concentrate, can't pay attention for long
|
[ ] |
[ ] |
[ ] |
| 3. |
Can't sit still, restless, or hyperactive
|
[ ] |
[ ] |
[ ] |
| 4. |
Fidgets
|
[ ] |
[ ] |
[ ] |
| 5. |
Daydreams or gets lost in his/her thoughts
|
[ ] |
[ ] |
[ ] |
| 6. |
Impulsive or acts without
thinking
|
[ ] |
[ ] |
[ ] |
| 7. |
Difficulty following
directions
|
[ ] |
[ ] |
[ ] |
| 8. |
Talks out of turn
|
[ ] |
[ ] |
[ ] |
| 9. |
Messy work
|
[ ] |
[ ] |
[ ] |
| 10. |
Inattentive, easily distracted |
[ ] |
[ ] |
[ ] |
| 11. |
Talks too much |
[ ] |
[ ] |
[ ] |
| 12. |
Fail to carry out assigned tasks
|
[ ] |
[ ] |
[ ] |
Please feel free to write any comments about the pupil's
work or behavior in the last week:
|