Associated Psychologists

Marnie Smith Dillon, Psy.D.

4146 Carmichael Court

Montgomery, Alabama 36106

(334)409-0210, facsimile (334) 409-0250

Behavior Rating Scale: Teacher Version

Child’s Name:______Date:______

Name of Person Completing this form: ______

What class(es) do you teach this child?______

In a typical day, how many hours do you observe this child? ______

Name and Address of School: ______

Please circle the number next to each item that best

describes the behavior of this child during the past six months.

Section A / Never or Rarely / Sometimes / Often / Very Often
1. Fails to give close attention to details or makes careless mistakes / 0 / 1 / 2 / 3
2. Has difficulty sustaining attention in tasks or play activities. / 0 / 1 / 2 / 3
3. Does not seem to listen when spoken to directly / 0 / 1 / 2 / 3
4. Does not follow through on instructions and fails to finish work / 0 / 1 / 2 / 3
5. Has difficulty organizing tasks and activities / 0 / 1 / 2 / 3
6. Avoids tasks (e.g. schoolwork, homework) that require mental effort / 0 / 1 / 2 / 3
7. Loses things necessary for tasks or activities / 0 / 1 / 2 / 3
8. Is easily distracted / 0 / 1 / 2 / 3
9. Is forgetful in daily activities / 0 / 1 / 2 / 3
Section B / Never or Rarely / Sometimes / Often / Very Often
1. Fidgets with hands or feet or squirms in seat / 0 / 1 / 2 / 3
2. leaves seat in classroom or in other situations in which seating is expected / 0 / 1 / 2 / 3
3. Seems restless / 0 / 1 / 2 / 3
4. Has difficulty playing or engaging in leisure activities quietly / 0 / 1 / 2 / 3
5. Is “on the go” or acts as if “driven by a motor” / 0 / 1 / 2 / 3
6. Talks excessively / 0 / 1 / 2 / 3
7. Blurts out answers before questions have been completed / 0 / 1 / 2 / 3
8. Has difficulty awaiting turn / 0 / 1 / 2 / 3
9. Interrupts or intrudes on others / 0 / 1 / 2 / 3

Instructions: To what extent do the problems you may have circled above interfere with this child’s ability to function in each of these areas of school activities during the past six months?

Areas / Never or Rarely / Sometimes / Often / Very Often
1. Completion of Class work / 0 / 1 / 2 / 3
2. Completion of homework assignments / 0 / 1 / 2 / 3
3. Behavior in the school classroom / 0 / 1 / 2 / 3
4. Behavior on the school bus / 0 / 1 / 2 / 3
5. In sports, clubs, or other organizations held at school / 0 / 1 / 2 / 3
6. Interactions with classmates / 0 / 1 / 2 / 3
7. Play or recreational activities at recess / 0 / 1 / 2 / 3
8. Behavior in the lunchroom at school / 0 / 1 / 2 / 3

Again, please circle the number next to each item that best describes the behavior of this child during the last six months.

Section C / Never or Rarely / Sometimes / Often / Very Often
1. Loses temper / 0 / 1 / 2 / 3
2. Argues with adults / 0 / 1 / 2 / 3
3. Actively defies or refuses to comply with adults’ requests or rules / 0 / 1 / 2 / 3
4. Deliberately annoys people / 0 / 1 / 2 / 3
5. Blames others for his/her mistakes or misbehavior / 0 / 1 / 2 / 3
6. Is touchy or easily annoyed by others / 0 / 1 / 2 / 3
7. Is angry or resentful / 0 / 1 / 2 / 3
8. Is spiteful or vindictive / 0 / 1 / 2 / 3

You may use the space below to furnish additional

information that may assist us in providing services to this child.

______

Please fax (334-409-0250) or mail this information directly to our office. Thank You!