Impireum Assessment Scale—TEACHER Informant Impireum Assessment Scale—TEACHER Informant"*" indicates required fieldsTeacher’s Name:*Class Time:* Hours: Minutes AMPM AM/PMClass Name/Period:*Today’s Date:* MM slash DD slash YYYY Child’s Name:*Grade Level:*Email* 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. Please indicate the number of weeks or months you have been able to evaluate the behaviors:Is this evaluation based on a time when the child* was on medication was not on medication not sure?Symptoms1. Fails to give attention to details or makes careless mistakes in schoolwork* Never Occasionally Often Very Often2. Has difficulty sustaining attention to tasks or activities* Never Occasionally Often Very Often3. Does not seem to listen when spoken to directly* Never Occasionally Often Very Often4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand)* Never Occasionally Often Very Often5. Has difficulty organizing tasks and activities* Never Occasionally Often Very Often6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort* Never Occasionally Often Very Often7. Loses things necessary for tasks or activities (school assignments,pencils, or books)* Never Occasionally Often Very Often8. Is easily distracted by extraneous stimuli* Never Occasionally Often Very Often9. Is forgetful in daily activities* Never Occasionally Often Very Often10. Fidgets with hands or feet or squirms in seat* Never Occasionally Often Very Often11. Leaves seat in classroom or in other situations in which remaining seated is expected* Never Occasionally Often Very Often12. Runs about or climbs excessively in situations in which remaining seated is expected* Never Occasionally Often Very Often13. Has difficulty playing or engaging in leisure activities quietly* Never Occasionally Often Very Often14. Is “on the go” or often acts as if “driven by a motor”* Never Occasionally Often Very Often15. Talks excessively* Never Occasionally Often Very Often16. Blurts out answers before questions have been completed* Never Occasionally Often Very Often17. Has difficulty waiting in line* Never Occasionally Often Very Often18. Interrupts or intrudes on others (eg, butts into conversations/games)* Never Occasionally Often Very Often19. Loses temper* Never Occasionally Often Very Often20. Actively defies or refuses to comply with adult’s requests or rules* Never Occasionally Often Very Often21. Is angry or resentful* Never Occasionally Often Very Often22. Is spiteful and vindictive* Never Occasionally Often Very Often23. Bullies, threatens, or intimidates others* Never Occasionally Often Very Often24. Initiates physical fights* Never Occasionally Often Very Often25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others)* Never Occasionally Often Very Often26. Is physically cruel to people* Never Occasionally Often Very Often27. Has stolen items of nontrivial value* Never Occasionally Often Very Often28. Deliberately destroys others’ property* Never Occasionally Often Very Often29. Is fearful, anxious, or worried* Never Occasionally Often Very Often30. Is self-conscious or easily embarrassed* Never Occasionally Often Very Often31. Is afraid to try new things for fear of making mistakes* Never Occasionally Often Very Often32. Feels worthless or inferior* Never Occasionally Often Very Often33. Feels worthless or inferior* Never Occasionally Often Very Often34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”* Never Occasionally Often Very Often35. Is sad, unhappy, or depressed* Never Occasionally Often Very OftenAcademic Performance36. Reading* Excellent Above Average Average Somewhat of a Problem Problematic37. Mathematics* Excellent Above Average Average Somewhat of a Problem Problematic38. Written expression* Excellent Above Average Average Somewhat of a Problem ProblematicClassroom Behavioral Performance39. Relationship with peers* Excellent Above Average Average Somewhat of a Problem Problematic40. Following directions* Excellent Above Average Average Somewhat of a Problem Problematic41. Disrupting class* Excellent Above Average Average Somewhat of a Problem Problematic42. Assignment completion* Excellent Above Average Average Somewhat of a Problem Problematic43. Organizational skills* Excellent Above Average Average Somewhat of a Problem ProblematicComments:*
