SNAP-IV 26 – Teacher and Parent Rating Scale

Source: James M. Swanson, Ph.D., University of California, Irvine, CA 92715

PRIVATE & CONFIDENTIAL

Completed by a Teacher of a patient
For assistance with this form contact Telecare: 03 9034 9950

Please complete all required fields and submit your form at least 72 hours prior to the patient's appointment. This form will be provided to the patient's specialist doctor.

Teacher Details

Your Name *

Relationship to the Patient *

Other *

CHILD (Patient) Details

Patient's First Name *

Patient's Last Name *

Date of Birth

Questionnaire

Please select the most appropriate option that best describes the patient's behaviour

0 = Never or Rarely: This is not a problem or concern. Any challenges are/were age-appropriate

1 = Sometimes: Some difficulty (somewhat)

2 = Often: This is a problem (pretty much)

3 = Very Often: This is a serious problem (very much)

Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks *

0123

Often has difficulty sustaining attention in tasks or play activities *

0123

Often does not seem to listen when spoken to directly *

0123

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties *

0123

Often has difficulty organizing tasks and activities *

0123

Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort *

0123

Often loses things necessary for activities (e.g., toys, school assignments, pencils, or books) *

0123

Often is distracted by extraneous stimuli *

0123

Often is forgetful in daily activities *

0123

Often fidgets with hands or feet or squirms in seat *

0123

Often leaves seat in classroom or in other situations in which remaining seated is expected *

0123

Often runs about or climbs excessively in situations in which it is inappropriate *

0123

Often has difficulty playing or engaging in leisure activities quietly *

0123

Often is “on the go” or often acts as if “driven by a motor” *

0123

Often talks excessively *

0123

Often blurts out answers before questions have been completed *

0123

Often has difficulty awaiting turn *

0123

Often interrupts or intrudes on others (e.g. butts into conversations/ games) *

0123

Often loses temper *

0123

Often argues with adults *

0123

Often actively defies or refuses adult requests or rules *

0123

Often deliberately does things that annoy other people *

0123

Often blames others for his or her mistakes or misbehavior *

0123

Often touchy or easily annoyed by others *

0123

Often is angry and resentful *

0123

Often is spiteful or vindictive *

0123

Areas

SIGNATURE

I confirm the above information I have provided is true, complete and accurate. *

Teacher's Signature *

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Today's Date *

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