Teacher First Assessment FormTeacher Assessment form for the First Doctor consultation Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year. Step 1 of 616%School Name*School currently attending.Teachers's Name* First Last Teacher's Email* Enter Email Confirm Email School Email* Enter Email Confirm Email Child's Name* First Last Grade*Please enter a number from 00 to 12.Today’s Date* Date Format: DD slash MM slash YYYY Additional information about type of classNormal stream. Remedial. Or specialised classPlease indicate in months time you have been able to evaluate the behaviours:Please enter a number from 1 to 12. Save and Continue LaterSymptoms*Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year.NeverOccasionalOftenVery OftenNot Applicable1.Fails to give attention to details or makes careless mistakes in schoolwork2. Has difficulty sustaining attention to tasks or activities3. Does not seem to listen when spoken to directly4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand).5. Has difficulty organizing tasks and activities6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)8. Is easily distracted by noises or other stimuli9. Is forgetful in daily activities10. Fidgets with hands or feet or squirms in seat11. Leaves seat when remaining seated is expected12. Runs about or climbs too much when remaining seated is expected13. Has difficulty playing or beginning quiet play activities14. Is “on the go” or often acts as if “driven by a motor”15. Talks excessively16. Blurts out answers before questions have been completed17. Has difficulty waiting his or her turn (waiting in line)18. Interrupts or intrudes on others (eg, butts into conversations/games)19. Loses temper20. Actively defies or refuses to comply with adult’s requests or rules21. Is angry or resentful22. Is spiteful and vindictive23. Bullies, threatens, or intimidates others24. Initiates physical fights25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others)26. Is physically cruel to people27. Has stolen items of value28. Deliberately destroys others’ property29. Is fearful, anxious, or worried30. Is self-conscious or easily embarrassed31. Is afraid to try new things for fear of making mistakes32. Feels worthless or inferior33. Blames self for problems; feels guilty34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”35. Is sad, unhappy, or depressed Save and Continue LaterAcademic performance*ExcellentAbove averageAverageSomewhat a ProblemProblematic36. Reading37. Mathematics38. Written expression Save and Continue LaterClassroom Behavioral Performance.*ExcellentAbove averageAverageSomewhat a ProblemProblematic39. Relationship with peers40. Following directions41. Disrupting class42. Assignment completion43. Organizational skillsIs this evaluation based on a time when the child is on medication?* was on medication was not on medication not sure? Save and Continue Later*Well Below Grade LevelSome what BelowAt Grade LevelSome what aboveWell AboveNot ApplicableReading: DecodingReading: ComprehensionReading: FluencyWriting: HandwritingWriting: SpellingWriting: Written syntax (sentence level)Writing: Written composition (text level)Mathematics: Computation (accuracy)Mathematics: Computation (fluency)Mathematics: Applied mathematical reasoningClassroom Performance: Following directions/instructionsClassroom Performance: Organisational skillsClassroom Performance: Peer relationshipsClassroom Performance: Classroom Behaviour Save and Continue LaterStrengths: What are this student's strengths?*Education plan: If this student has an education plan, what are the recommendations? Do they work?*Accommodations: What accommodations are in place? Are they effective?*Class Instructions: How well does this student handle large-group instruction? Does s/he follow instructions well? Can s/he wait for a turn to respond? Would s/he stand out from same-sex peers? In what way?*Individual seat work: How well does this student self-regulate attention and behaviour during assignments to be completed as individual set work? Is the work generally completed? Would s/he stand out from same-sex peers?In what way?*Transitions: How does this student handle transitions such as going in and out for recess, changing classes or changing clothing.*Conflict and Aggression: – Is s/he often in conflict with adults or peers? How does s/he resolve arguments? Is the student verbally or physically aggressive? Is s/he the target of verbal or physical aggression by peers?*Academic Abilities: We would like to know about this student's general abilities and academic skills.*Self-help skills, independence, problem solving, activities of daily living*Please comment on any concerns.Motor Skills (gross/fine): Does this student have problems with gym, sports, writing? If so, please describe.*Written output: Does this student have problems putting ideas down in writing? If so, please describe.*Primary Areas of concern: What are your major areas of concern/worry for this student? How long has this/these been a concern for you?*Impact on student: To what extent are these difficulties for the student upsetting or distressing to the student him/ herself, to you and/or the other students?*Impact on the class: Does this student make it difficult for you to teach the class?*Medications: If this student is on medication, is there anything you would like to highlight about the differences when s/he is on?*Parent involvement: What has been the involvement of the parent(s)?*Are the problems with attention and/or hyperactivity interfering with the student's learning? Peer relationships?*Has the student had any particular problems with homework or handing in assignments?*Is there anything else you would like us to know? If you feel the need to contact the student's clinician during this assessment please feel free to do so* Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.