Teacher Standard Form

(Ages 5 – 18)

James L. McDougal, Psy.D., Achilles N. Bardos, Ph.D., & Scott T. Meier, Ph.D.

Student ID: _______________________________

Student Name: ______________________________

School: _________________________________________________________

Grade: ___________________________________

Class Name: ______________________________

Today's Date: ____/____/___________(MM/DD/YYYY)

Student's Date of Birth: ___/___/_____ (MM/DD/YYYY)

Instructions: On the next page, please rate how often this student
displayed each of the following behaviors during the past week. For
each item, ask yourself "How often did this behavior occur in the past
week?". Then, shade in the best answer for each one. Please shade
only one answer for each item. It is important to respond to every
item. For items that you find difficult to answer, please give your best
guess.

Please turn the page.

 Teacher Standard Form
(Ages 5 – 18)

James L. McDougal, Psy.D., Achilles N. Bardos, Ph.D., & Scott T. Meier, Ph.D.

0 = Never (0 times or not observed)

1 = Rarely (Observed 1-2 times or to a minimal extent)
Rating: 2 = Sometimes (Observed 3-4 times or to a moderate extent)
During the past week, this student... 3 = Often (Observed 5-6 times or to a significant extent)
4 = Very Often (Observed 7 or more times or to an extreme extent)

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During the past week, this student...

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1. shared what they were thinking about. 0 1 2 3 4
2. appeared angry. 0 1 2 3 4
3. had trouble paying attention. 0 1 2 3 4
4. followed directions. 0 1 2 3 4
5. appeared sleepy or tired. 0 1 2 3 4
6. was impulsive. 0 1 2 3 4
7. spoke clearly with others. 0 1 2 3 4
8. appeared depressed. 0 1 2 3 4
9. engaged in risk-taking behavior. 0 1 2 3 4
10. had problems staying on task. 0 1 2 3 4
11. maintained friendships. 0 1 2 3 4
12. acted sad or withdrawn. 0 1 2 3 4
13. fought with others (verbally, physically, or both). 0 1 2 3 4
14. acted without thinking. 0 1 2 3 4
15. appeared comfortable when relating to others. 0 1 2 3 4
16. was easily embarrassed or felt ashamed. 0 1 2 3 4
17. lied or cheated. 0 1 2 3 4
18. had trouble remembering. 0 1 2 3 4
19. was generally friendly with others. 0 1 2 3 4
20. appeared anxious (worried or nervous). 0 1 2 3 4
21. lost his/her temper when upset. 0 1 2 3 4
22. had trouble with organizing and planning. 0 1 2 3 4
23. worked out problems with others. 0 1 2 3 4
24. expressed thoughts of hurting himself/herself. 0 1 2 3 4
25. was aggressive (threatened or bullied others). 0 1 2 3 4
26. received failing grades at school. 0 1 2 3 4
27. was emotional or upset. 0 1 2 3 4
28. fidgeted. 0 1 2 3 4
29. was suspected of using alcohol and/or drugs. 0 1 2 3 4
30. worked up to his/her academic potential. 0 1 2 3 4
31. was sent to an authority for discipline. 0 1 2 3 4
32. was suspected of smoking or chewing tobacco. 0 1 2 3 4
33. was prepared for class. 0 1 2 3 4

34. was absent from school. 0 1 2 3 4

Thank you for completing this questionnaire.

Please make sure you have answered every item.
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