TODAY’S DATE Mo. ____ Day ____ Year _____ Your role: ⬥ teacher ⬥ caregiver Below is a list of items that describe children. For each item that describes the child over the past 30 min, please circle the 2 if the item is very true or often true of the child. Circle the 1 if the item is somewhat or sometimes true of the child. If the item is not true of the child, circle the 0. Please answer all items as well as you can, even if some do not seem to apply to the child. 0 = Not True 1 = Somewhat or Sometime True 2 = Very True or Often True
Anxious/Depressed	0	1	2	1. Clings to adults or too dependent
	0	1	2	2. Feelings are easily hurt
	0	1	2	3. Gets too upset when separated from parents
	0	1	2	4. Looks unhappy without good reason
	0	1	2	5. Nervous, high-strung, or tense
	0	1	2	6. Self-conscious or easily embarrassed
	0	1	2	7. Too fearful or anxious
	0	1	2	8. Unhappy, sad, or depressed
Attention Problem	0	1	2	9. Cannot concentrate, cannot pay attention for long
	0	1	2	10. Cannot sit still, restless, or hyperactive
	0	1	2	11. Difficulty following directions
	0	1	2	12. Fails to carry out assigned tasks
	0	1	2	13. Fidgets
	0	1	2	14. Poorly coordinated or clumsy
	0	1	2	15. Quickly shifts from one activity to another
	0	1	2	16. Inattentive, easily distracted
	0	1	2	17. Wanders away