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Behavior Rating Scale-Teachers

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John E. Dunne, M.D.

Bus: (206) 243-7383


16040 Christensen Rd. Suite 217 Fax: (206) 241-7346
Tukwila, Washington 98188
BEHAVIOR RATING SCALE – TEACHER FORM
Child’s Name:_______________________________________ Date:_____________________
Name of person completing this form:_______________________________________________________
Teaches: (subject)__________________________________

Instructions: Please circle the number next to each item that best describes the behavior of this child during the last six
(6) months.
Never Very
Items: or Rarely Sometimes Often Often
1. Fails to give close attention to details
or makes careless mistakes in his/her work 0 1 2 3
2. Fidgets with hands or feet or squirms in seat 0 1 2 3
3. Has difficulty sustaining his/her attention
in tasks or fun activities 0 1 2 3
4. Leaves his/her seat in classroom or in other
situations in which seated is expected 0 1 2 3
5. Doesn’t listen when spoken to directly 0 1 2 3
6. Seems restless 0 1 2 3
7. Doesn’t follow through on instructions and
fails to finish work 0 1 2 3
8. Has difficulty engaging in leisure activities
or doing fun things quietly 0 1 2 3
9. Has difficulty organizing tasks and activities 0 1 2 3
10. Feels “on the go” or “driven by a motor” 0 1 2 3
11. Avoids, dislikes, or is reluctant to engage in
work that requires sustained mental effort 0 1 2 3
12. Talks excessively 0 1 2 3
13. Loses things necessary for tasks or activities 0 1 2 3
14. Blurts out answers before questions have been
completed 0 1 2 3
15. Is easily distracted 0 1 2 3
16. Has difficulty awaiting turn 0 1 2 3
17. Is forgetful in daily activities 0 1 2 3
18. Interrupts or intrudes on other 0 1 2 3
How old was this child when you noticed the above problems? ____________

Instructions: To what extent do the problems circled above interfere with this child’s ability to function in each of these
areas of school activities during the past six (6) months?
Never Very
Items: or Rarely Sometimes Often Often
1. In his/her home life with my immediate family 0 1 2 3
2. In his/her interactions with other children 0 1 2 3
3. In his/her activities or dealings in the community 0 1 2 3
4. In school 0 1 2 3
5. In sports, clubs, or other organizations 0 1 2 3
6. In learning to take car of him/herself 0 1 2 3
7. In his/her play, leisure, or recreational activities 0 1 2 3
8. In his/her handling of daily chores or other
responsibilities 0 1 2 3
9. In his/her management of time at school 0 1 2 3
Behavior Rating Scale – Teacher Form (Page 2 of 2)

Instructions: Again, please circle the number next to each item that best describes the behavior of this child during the
last six (6) months.
Never Very
Items: or Rarely Sometimes Often 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

Thank you for your help.

Please send this form back to us by mail or, to save time and postage, you may fax it back to us at (206)
241-7346.

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