G Please prin CAREGIVER-TEACHER REPORT FORM FOR AGES 17-5 Foren oy CHILDS ‘First Middle Last FULL NAME ‘CHILD'S GENDER CHILD'SAGE | CHILD'S ETHNIC Opoy Cais GROUP. LOR RACE TODAY'S DATE CHILD'S BIRTHDATE Mo. Day__Year__ | Mo,__Day__Year_ Please fil out this form to reflect your view of the child's behavior even if other people might not agree. Feel free to write additional comments beside each item and in the space provided on page 2. Be sure to answer all items Name & address of school or care facility: PARENTS’ USUAL TYPE OF WORK, even Ifnot working now. lease be specie — for example, auto mechanic, high school teacher, homemaker, laborer, lathe operaicr, shoe salesmen, amy sergeant. PARENT 1 (er FATHER) PARENT 2 (or MOTHER), THIS FORM FILLED OUT BY: (print your fullname) Your role at the schoo! or care fact: primary educational teacher) C2 primanly care (caregiver) "Your training fo this positon: ‘Your experience in childcare or early education: years |. What kind of facility is it? (Please be specifi e.g., home day care, day care center, nursery school, preschool, school readiness class, Early Childhood Special Education, Headstart, Kindergarten, tc.) I. What isthe average number of children in the chlc's group or class? IIL. How many hours per week does this child spend at the facility? IV, Forhow many months have you known this child? children in the child's group or class. hours per week. months. \V. How well do you know him/her? 1.0 Notwell 2. Moderately well 3.0 Very well VI. Has he/she ever been referred for a special education program or special services? 1 Don'tknow 0.CNo 1,0 Yes —what kind and when? Below is ai list of tems that describe children. For each item that describes the ck now of within the past 2 months, 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 = Not True (as faras you know) 1 ‘Somewhat or Sometimes True 2= Very True or Often True 0 1 2 1. Aches or pains (without medical cause; do not include stomach or headaches) ‘Acts too young for age Afraid to try new things ‘Avoids looking others in the eye Can't concentrate, can't pay attention for long Can't sit stil, restless or hyperactive Can't stand having things out of place Can't stand waiting; wants everything now 9. Chews on things that aren't edible 10. Clings to adults or too dependent ‘114. Constantly seeks help 12. Apathetic or unmotivated 13. Gries alot 414, Cruel to animals 16, Defiant 46, Demands must be met immediately 47. Destroys his/her own things 18, Destroys property belonging to others 49. Daydreams or gets lost in histher thoughts 20. Disobedient 2-21. Disturbed by any change in routine ° 0 1 2 22, Cruelty, bullying, or meanness to others 0 1 2 23, Doesn't answer when people talk to him/her 0 1 2 24. Difficulty folowing directions 0 1 2 25. Doesn't get along with other children 0 1 2 26, Doesn't know how to have fun; acts lke a Tite adult 0 1 2 27. Doesn't seem to fee! guilty after misbehaving (0 1 2 28, Disturbs other children 01 2 29, Easily frustrated 101 2 30. Easily jealous 0 1 2 31. Eats or drinks things that are not food — do not. include sweets (describe: 10 1 2 92, Fears certain animals, situations, or places other than daycare or school (describe): 0 1 2 33.Feeiings are easily hurt 0 1 2 34, Gets hurtallot, accident-prone 0 1 2. 35.Gets in many fights 0 1 2 36.Gets into everything © 4 2. 37. Gets too upset when separated from parents Copyright 1997 Achenbach ASEBA, University of Vermont, 1 S. Prospect St, Bufington, VT 05401-3456 ‘Webs wiv asebaorg ‘UNAUTHORIZED REPRODUCTION IS ILLEGAL Be sure you have answered all items. Then see other side. 6-23-44 Ealtion-2010 = Not True (as far as you know) Please print your answers. Be sure to answer all items. ‘4. = Somewhat or Sometimes True = Very True or Often True 012 oa O08 o12 chez) O14 Oa A cena) cee Cie nee ones cee ae clea ciara cues (oleae cle cee o4 o4 cee hee ones a iP a2 cies foe oats cle omnes cee 38, 39, 40. 41, 42, 43, 44, 45. 46. 47. 48 49. 50. 51 62, 53. 54, 55, 56. 87. 68. 59, 60. 6 62, 63, 64, 65. 66. 67. 68. 69. 70. Explosive and unpredictable behavior Headaches (without medical cause) Hits others: Holds his/her breath Hurts animals or people without meaning to Looks unhappy without good reason ‘Angry moods Nausea, feels sick (without medical cause) Nervous movements or twitching (describe): Nervous, highstrung, or tense Falls to carry out assigned tasks Fears daycare or school Overtired Fidgets Gets teased by other children Physically attacks people Picks nose, skin, or other parts of body (describe): Plays with own sex parts too much Poorly coordinated or clumsy Problems with eyes without medical cause (desoribe) Punishment doesn't change his/her behavior Quickly shifts from one activity to another Rashes or other skin problems (without medical cause) Refuses to eat Refuses to play active games Repeatedly rocks head or body Inattentive, easily distracted Lying or cheating Screams a lot Seems unresponsive to affection Sel-conscious or easily embarrassed. Selfish or won't share Shows litle affection toward people 0 2 a 72, 73. 74, 7. 76 7 78 79. 80. 81. 82, 23, 84, 85, 86, 87. 88. 89. 90. a1 92, 93, 95. 96. 97, 96. 98. 100. ‘Shows litle interest in things around him/her ‘Shows too litle fear of geting hurt Too shy or timid NNot liked by other children. Overactive ‘Speech problem (describe): Slates into space or seems preoccupied ‘Stomachaches or cramps (without medical cause) COverconforms to rules Strange behavior (describe): SStubbom, sullen, or iritable ‘Sudden changes in mood or feelings Sulks a lot ‘oases a lot ‘Temper tantrums or hot temper Too concerned with neatness or cleanliness Too fearful or anxious Uncooperative Underactive, stow moving, or lacks energy Unhappy, sad, or depressed Unusually loud Upset by new people or situations (describe): Vomiting, throwing up (without medical cause) Unciean personal appearance Wanders away Wants a lot of attention Whining ‘Withdrawn, doesn't get involved with others Worries, Please wte in any problems the child has that were not listed above. Please be sure you answered all items. Underline any you are concerned about. Does the child have any iliness or disability either physical or mental)? C1 No Clyes—Piease describe: What concerns you most about the child? Please describe the best things about the child: PAGE 2