For office use only

Please print TEACHERS REPORT FORM FOR AGES 6-18 ID #

Your answers will be used to compare the pupil with other pupils whose teachers have completed similar forms. The information from this form
will also be used for comparison with other information about this pupil. Please answer as well as you can, even if you lack full information.
Scores on individual items will be combined to identify general patterns of behavior. Feel free to print additional comments beside each item
and in the spaces provided on page 2. Please print, and answer all items.

PUPILS First Middle Last PARENTS USUAL TYPE OF WORK, even if not working now.
FULL (Please be specific for example, auto mechanic, high school teacher,
NAME homemaker, laborer, lathe operator, shoe salesman, army sergeant.)
FATHERS
PUPILS GENDER PUPILS AGE PUPILS ETHNIC GROUP TYPE OF WORK __________________________________________
OR RACE MOTHERS
Boy Girl TYPE OF WORK __________________________________________

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TODAYS DATE PUPILS BIRTHDATE (if known) THIS FORM FILLED OUT BY: (print your full name)

Mo. _____ Day ____ Year _____ Mo. ____ Day ____ Year ____ _______________________________________________________

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GRADE IN NAME AND ADDRESS OF SCHOOL Your gender: Male Female
SCHOOL
________________________________ Your role at the school:

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________________________________ Classroom Teacher Counselor Teachers Aide
___________
________________________________

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Special Educator Administrator Other (specify)

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I. For how many months have you known this pupil? ______ months

II. How well do you know him/her? 1. Not Well 2. Moderately Well 3. Very Well

III. How much time does he/she spend in your class or service per week?

IV. What kind of class or service is it? (Please be specific, e.g., regular 5th grade, 7th grade math, learning disability,
counseling, etc.)

V. Has he/she ever been referred for special class placement, services, or tutoring?
Dont know 0. No 1. Yes what kind and when?

VI. Has he/she ever repeated any grades? Dont Know 0. No 1. Yes grades and reasons:

VII. Current academic performance list academic subjects and check box that indicates pupils performance for each subject:

1. Far below 2. Somewhat 3. At grade 4. Somewhat 5. Far above

Academic subject grade below grade level above grade grade

1. ____________________

2. ____________________

3. ____________________

4. ____________________

5. ____________________

6. ____________________

Be sure you answered all items. Then see other side.

Copyright 2001 T. Achenbach UNAUTHORIZED COPYING IS ILLEGAL 6-1-01 Edition - 301
ASEBA, University of Vermont
1 South Prospect St., Burlington, VT 05401-3456
www.ASEBA.org PAGE 1
 Please print. Be sure to answer all items.

VIII. Compared to typical pupils 1. Much 2. Somewhat 3. Slightly 4. About 5. Slightly 6. Somewhat 7. Much
of the same age: less less less average more more more

1. How hard is he/she working?

2. How appropriately is he/she

behaving?

3. How much is he/she learning?

4. How happy is he/she?

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IX. Most recent achievement test scores (optional):

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Percentile or
Name of test Subject Date grade level obtained

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X. IQ, readiness, or aptitude tests (optional):

Name of test Date IQ or equivalent scores

Does this pupil have any illness or disability (either physical or mental)? No Yes please describe:

What concerns you most about this pupil?

Please describe the best things about this pupil:

Please feel free to write any comments about this pupils work, behavior, or potential, using extra pages if necessary.

PAGE 2
 Please print. Be sure to answer all items.
Below is a list of items that describe pupils. For each item that describes the pupil now or within the past 2 months,
please circle the 2 if the item is very true or often true of the pupil. Circle the 1 if the item is somewhat or sometimes true
of the pupil. If the item is not true of the pupil, circle the 0. Please answer all items as well as you can, even if some do not
seem to apply to this pupil.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True

0 1 2 1. Acts too young for his/her age 0 1 2 34. Feels others are out to get him/her
0 1 2 2. Hums or makes other odd noises in class 0 1 2 35. Feels worthless or inferior

0 1 2 3. Argues a lot 0 1 2 36. Gets hurt a lot, accident-prone

0 1 2 4. Fails to finish things he/she starts 0 1 2 37. Gets in many fights

0 1 2 5. There is very little he/she enjoys 0 1 2 38. Gets teased a lot

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0 1 2 6. Defiant, talks back to staff 0 1 2 39. Hangs around with others who get in trouble

0 1 2 7. Bragging, boasting 0 1 2 40. Hears sound or voices that arent there

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0 1 2 8. Cant concentrate, cant pay attention for long (describe): ________________________
________________________________
0 1 2 9. Cant get his/her mind off certain thoughts;

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0 1 2 41. Impulsive or acts without thinking
obsessions (describe): _______________

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__________________________________ 0 1 2 42. Would rather be alone than with others

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0 1 2 10. Cant sit still, restless, or hyperactive 0 1 2 43. Lying or cheating

0 1 2 11. Clings to adults or too dependent 0 1 2 44. Bites fingernails

0 1 2 12. Complains of loneliness 0 1 2 45. Nervous, highstrung, or tense

0 1 2 13. Confused or seems to be in a fog 0 1 2 46. Nervous movements or twitching (describe):

0 1 2 14. Cries a lot ________________________________
________________________________
0 1 2 15. Fidgets
0 1 2 47. Overconforms to rules
0 1 2 16. Cruelty, bullying, or meanness to others
0 1 2 48. Not liked by other pupils
0 1 2 17. Daydreams or gets lost in his/her thoughts
0 1 2 49. Has difficulty learning
0 1 2 18. Deliberately harms self or attempts suicide
0 1 2 50. Too fearful or anxious
0 1 2 19. Demands a lot of attention
0 1 2 51. Feels dizzy or lightheaded
0 1 2 20. Destroys his/her own things
0 1 2 52. Feels too guilty
0 1 2 21. Destroys property belonging to others
0 1 2 53. Talks out of turn
0 1 2 22. Difficulty following directions
0 1 2 54. Overtired without good reason
0 1 2 23. Disobedient at school
0 1 2 55. Overweight
0 1 2 24. Disturbs other pupils
56. Physical problems without known medical
0 1 2 25. Doesnt get along with other pupils
cause:
0 1 2 26. Doesnt seem to feel guilty after misbehaving
0 1 2 a. Aches or pains (not stomach or headaches)
0 1 2 27. Easily jealous 0 1 2 b. Headaches
0 1 2 28. Breaks school rules 0 1 2 c. Nausea, feels sick
0 1 2 d. Eye problems (not if corrected by glasses)
0 1 2 29. Fears certain animals, situations, or places,
(describe): ________________________
other than school (describe): ____________
________________________________
___________________________________
0 1 2 e. Rashes or other skin problems
0 1 2 30. Fears going to school
0 1 2 f. Stomachaches
0 1 2 31. Fears he/she might think or do something bad 0 1 2 g. Vomiting, throwing up
0 1 2 32. Feels he/she has to be perfect 0 1 2 h. Other (describe): ___________________
________________________________
0 1 2 33. Feels or complains that no one loves him/her ________________________________

PAGE 3 Be sure you answered all items. Then see other side.
 Please print. Be sure to answer all items.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True

0 1 2 57. Physically attacks people 0 1 2 84. Strange behavior (describe): _________

0 1 2 58. Picks nose, skin, or other parts of body ________________________________
(describe): _______________________ 0 1 2 85. Strange ideas (describe): ____________
________________________________ ________________________________

0 1 2 59. Sleeps in class 0 1 2 86. Stubborn, sullen, or irritable

0 1 2 60. Apathetic or unmotivated 0 1 2 87. Sudden changes in mood or feelings

0 1 2 61. Poor school work 0 1 2 88. Sulks a lot

0 1 2 62. Poorly coordinated or clumsy 0 1 2 89. Suspicious

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0 1 2 63. Prefers being with older children or youths 0 1 2 90. Swearing or obscene language
0 1 2 64. Prefers being with younger children 0 1 2 91. Talks about killing self

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0 1 2 65. Refuses to talk 0 1 2 92. Underachieving, not working up to potential
0 1 2 66. Repeats certain acts over and over; 0 1 2 93. Talks too much

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compulsions (describe): _____________
0 1 2 94. Teases a lot

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________________________________
0 1 2 95. Temper tantrums or hot temper

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0 1 2 67. Disrupts class discipline
0 1 2 96. Seems preoccupied with sex
0 1 2 68. Screams a lot
0 1 2 97. Threatens people
0 1 2 69. Secretive, keeps things to self
0 1 2 98. Tardy to school or class
0 1 2 70. Sees things that arent there (describe):
0 1 2 99. Smokes, chews, or sniffs tobacco
________________________________
________________________________ 0 1 2 100. Fails to carry out assigned tasks
0 1 2 101. Truancy or unexplained absence
0 1 2 71. Self-conscious or easily embarrassed
0 1 2 72. Messy work 0 1 2 102. Underactive, slow moving, or lacks energy
0 1 2 103. Unhappy, sad, or depressed
0 1 2 73. Behaves irresponsibly (describe): _____
________________________________ 0 1 2 104. Unusually loud
________________________________ 0 1 2 105. Uses drugs for nonmedical purposes (dont
0 1 2 74. Showing off or clowning include tobacco) (describe): ___________
_________________________________
0 1 2 75. Too shy or timid
_________________________________
0 1 2 76. Explosive or unpredictable behavior
0 1 2 106. Overly anxious to please
0 1 2 77. Demands must be met immediately, easily
0 1 2 107. Dislikes school
frustrated
0 1 2 78. Inattentive or easily distracted 0 1 2 108. Is afraid of making mistakes
0 1 2 109. Whining
0 1 2 79. Speech problem (describe): __________
________________________________ 0 1 2 110. Unclean personal appearance
0 1 2 80. Stares blankly 0 1 2 111. Withdrawn, doesnt get involved with others

0 1 2 81. Feels hurt when criticized 0 1 2 112. Worries

0 1 2 82. Steals 113. Please write in any problems the pupil has
that were not listed above:
0 1 2 83. Stores up too many things he/she doesnt
0 1 2 _____________________________________
need (describe): __________________
0 1 2 _____________________________________
________________________________
0 1 2 _____________________________________
________________________________

PAGE 4 Please be sure you answered all items.