CDE Detailed Report

Disease: Traumatic Brain Injury
Subdomain Name: Psychiatric and Psychological Status
CRF: Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18

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CDE ID CDE Name Variable Name Definition Short Description Question Text Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guidance) Subdomain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
C55064 Child Behavior Checklist (CBCL) - Speech problem describe text CBCLSpeechProblemDescribeTxt The free-text field related to 'Child Behavior Checklist (CBCL) - Speech problem scale' for describing the child's speech problem, as part of the Child Behavior Checklist (CBCL) The free-text field related to 'Child Behavior Checklist (CBCL) - Speech problem scale' for describing the child's speech problem, as part of the Child Behavior Checklist (CBCL) Speech problem (describe) Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 12:55:52.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points 255

Free-Form Entry

C52293 Child Behavior Checklist (CBCL) - Sudden changes mood feelings scale CBCLSuddnChngMdFlngScl Scale for whether the child has sudden changes in mood or feelings, as part of the Child Behavior Checklist (CBCL) Scale for whether the child has sudden changes in mood or feelings, as part of the Child Behavior Checklist (CBCL) Sudden changes in mood or feelings 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-27 11:01:01.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52085 Child Behavior Checklist (CBCL) - Fails to finish things they start scale CBCLFailFinishThingStartScl Scale for whether the child fails to finish things they start, as part of the Child Behavior Checklist (CBCL) Scale for whether the child fails to finish things they start, as part of the Child Behavior Checklist (CBCL) Fails to finish things he/she starts. 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-21 12:39:02.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55023 Child Behavior Checklist (CBCL) - Academic performance subject code CBLCAcdmcPrfrmncSbjctCode Code for the academic performance of the child in the subject captured in 'Child Behavior Checklist (CBCL) - Academic performance subject type', as part of the Child Behavior Checklist (CBCL) Code for the academic performance of the child in the subject captured in 'Child Behavior Checklist (CBCL) - Academic performance subject type', as part of the Child Behavior Checklist (CBCL) Current academic performance 1;3;4;5;2 Far below grade;At grade level;Somewhat above grade;Far above grade;Somewhat below grade Numeric Values

Your answers will be used to compare the pupil with other pupils whose teachers have completed similar forms. The information on 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.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 11:31:38.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52242 Child Behavior Checklist (CBCL) - Gets teased a lot scale CBCLGetsTeasedALotScl Scale for whether the child gets teased a lot, as part of the Child Behavior Checklist (CBCL) Scale for whether the child gets teased a lot, as part of the Child Behavior Checklist (CBCL) Gets teased a lot 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 15:56:36.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55055 Child Behavior Checklist (CBCL) - Sleep class scale CBCLSleepClassScl Scale for the child's tendency to sleep in class, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to sleep in class, as part of the Child Behavior Checklist (CBCL) Sleeps in class 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 12:57:12.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C00020 Ethnicity USA category EthnUSACat Category of ethnicity the participant/subject most closely identifies with Category of ethnicity the participant/subject most closely identifies with Pupil's Ethnic Group or Race Hispanic or Latino;Not Hispanic or Latino;Unknown;Not reported;Other, specify A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term "Spanish origin" can also be used in addition to "Hispanic or Latino.";A person not meeting the definition for Hispanic or Latino.;Could not be determined or unsure;Not reported;Other, specify Alphanumeric Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

2192217
C55075 Child Behavior Checklist (CBCL) - Unclean personal appearance scale CBCLUncleanPersonalApearancScl Scale for the child's tendency to have an unclean personal appearance, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to have an unclean personal appearance, as part of the Child Behavior Checklist (CBCL) Unclean personal appearance 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 12:57:12.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52306 Child Behavior Checklist (CBCL) - Truancy skips school scale CBCLTrncySkpSchlScl Scale for whether the child displays truancy, or skips school, as part of the Child Behavior Checklist (CBCL) Scale for whether the child displays truancy, or skips school, as part of the Child Behavior Checklist (CBCL) Truancy or unexplained absence 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-27 12:25:56.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52106 Child Behavior Checklist (CBCL) - Inattentive or easily distracted scale CBCLInattentiveScl Scale for whether the child is inattentive or easily distracted, as part of the Child Behavior Checklist (CBCL) Scale for whether the child is inattentive or easily distracted, as part of the Child Behavior Checklist (CBCL) Inattentive or easily distracted 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 11:04:25.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55034 Child Behavior Checklist (CBCL) - Aptitude test score CBCLAptitudeTestScore The field related to 'Child Behavior Checklist (CBCL) - Aptitude test name' for specifying the child's score on the named aptitude test, as part of the Child Behavior Checklist (CBCL) The field related to 'Child Behavior Checklist (CBCL) - Aptitude test name' for specifying the child's score on the named aptitude test, as part of the Child Behavior Checklist (CBCL) IQ or equivalent scores Numeric Values

IQ, readiness, or aptitude tests (optional)

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 11:49:33.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Free-Form Entry

C52258 Child Behavior Checklist (CBCL) - Not liked by other kids scale CBCLNotLikedByOthrKidsScl Scale for whether the child is not liked by other kids, as part of the Child Behavior Checklist (CBCL) Scale for whether the child is not liked by other kids, as part of the Child Behavior Checklist (CBCL) Not liked by other pupils 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-23 10:39:18.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52278 Child Behavior Checklist (CBCL) - Self conscious easily embarrassed scale CBCLSlfCnsEslyEmbScl Scale for whether the child is self-conscious or easily embarrassed, as part of the Child Behavior Checklist (CBCL) Scale for whether the child is self-conscious or easily embarrassed, as part of the Child Behavior Checklist (CBCL) Self-conscious or easily embarrassed 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-27 09:21:17.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52037 Child Behavior Checklist (CBCL) - Headaches scale CBCLHeadachesScl Scale for whether the child Physical problems without known medical cause: Headaches, as part of the Child Behavior Checklist (CBCL) Scale for whether the child Physical problems without known medical cause: Headaches, as part of the Child Behavior Checklist (CBCL) Physical problems without known medical cause: Headaches 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-20 16:32:50.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55013 Child Behavior Checklist (CBLC) - Respondent school role type CBLCRespondentSchoolRoleTyp Type of role performed by the respondent at the child's school, as part of the Child Behavior Checklist (CBLC) Type of role performed by the respondent at the child's school, as part of the Child Behavior Checklist (CBLC) Your role at the school: Counselor;Administrator;Classroom Teacher;Teacher's Aide;Special Educator;Other, specify Counselor;Administrator;Classroom Teacher;Teacher's Aide;Special Educator;Other, specify Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Adult Supplemental 1.00 2017-04-18 11:00:27.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52209 Child Behavior Checklist (CBCL) - Aches or pains scale CBCLAchesPainsScl Scale for whether the child has aches or pains (not stomach or headaches) without known medical cause, as part of the Child Behavior Checklist (CBCL) Scale for whether the child has aches or pains (not stomach or headaches) without known medical cause, as part of the Child Behavior Checklist (CBCL) Physical problems without known medical cause: Aches or pains (not stomach or headaches) 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 14:07:23.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55045 Child Behavior Checklist (CBCL) - Prefer be alone scale CBCLPreferBeAloneScl Scale for the child's tendency to prefer being alone, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to prefer being alone, as part of the Child Behavior Checklist (CBCL) Would rather be alone than with others 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 12:04:30.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55065 Child Behavior Checklist (CBCL) - Feel hurt criticism scale CBCLFeelHurtCriticismScl Scale for the child's tendency to feel hurt by criticism, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to feel hurt by criticism, as part of the Child Behavior Checklist (CBCL) Feels hurt when criticized 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 12:57:12.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52294 Child Behavior Checklist (CBCL) - Sulks a lot scale CBCLSulkALotScl Scale for whether the child sulks a lot, as part of the Child Behavior Checklist (CBCL) Scale for whether the child sulks a lot, as part of the Child Behavior Checklist (CBCL) Sulks a lot 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-27 11:24:34.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52088 Child Behavior Checklist (CBCL) - Easily jealous scale CBCLEasilyJealousScl Scale for whether the child easily gets jealous, as part of the Child Behavior Checklist (CBCL) Scale for whether the child easily gets jealous, as part of the Child Behavior Checklist (CBCL) Easily jealous 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-21 13:52:14.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55024 Child Behavior Checklist (CBCL) - Work hard relative pupil typical same age code CBLCWrkHrdRelPplTypSamAgeCode Code for how hard the child works relative to typical pupils of the same age, as part of the Child Behavior Checklist (CBCL) Code for how hard the child works relative to typical pupils of the same age, as part of the Child Behavior Checklist (CBCL) How hard is he/she working? 4;1;2;3;5;6;7 About average;Much less;Somewhat less;Slightly less;Slightly more;Somewhat more;Much more Numeric Values

Compared to typical pupils of the same age

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 11:40:11.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52243 Child Behavior Checklist (CBCL) - Repeats certain acts over and over, compulsions description text CBCLRepeatActsCompulsionsTxt description text of the compulsions or the acts that the child repeats over and over, as part of the Child Behavior Checklist (CBCL) description text of the compulsions or the acts that the child repeats over and over, as part of the Child Behavior Checklist (CBCL) Repeats certain acts over and over, compulsions (describe) Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 16:02:43.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points 255

Free-Form Entry

C55056 Child Behavior Checklist (CBCL) - Apathy unmotivate scale CBCLApathyUnmotivateScl Scale for the child's tendency to exhibit apathy or lack of motivation, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to exhibit apathy or lack of motivation, as part of the Child Behavior Checklist (CBCL) Apathetic or unmotivated 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 12:57:12.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C00035 Gender type GenderTyp Self-reported gender of the participant/subject Self-reported gender of the participant/subjec Pupil's Gender Alphanumeric Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

2200604
C55076 Child Behavior Checklist (CBLC) - School grade repeat code CBLCSchoolGradeRepeatCode Code for the respondent's knowledge of whether the child has repeated a grade, as part of the Child Behavior Checklist (CBLC) Code for the respondent's knowledge of whether the child has repeated a grade, as part of the Child Behavior Checklist (CBLC) Has he/she repeadted any grades? Don't know;0;1 Don't know;No;Yes—grades and reasons: Alphanumeric

Your answers will be used to compare the pupil with other pupils whose teachers have completed similar forms. The information on 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.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 14:58:20.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52307 Child Behavior Checklist (CBCL) - Underactive slow moving lack energy scale CBCLUndrctvSlwMvLckEngScl Scale for whether the child is underactive, slow moving, or lacks energy, as part of the Child Behavior Checklist (CBCL) Scale for whether the child is underactive, slow moving, or lacks energy, as part of the Child Behavior Checklist (CBCL) Underactive, slow moving, or lacks energy 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-27 12:29:18.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52149 Child Behavior Checklist (CBCL) - Problems with eyes scale CBCLProbWithEyesScl Scale for whether the child has problems with eyes (not if corrected by glasses) without known medical cause, as part of the Child Behavior Checklist (CBCL) Scale for whether the child has problems with eyes (not if corrected by glasses) without known medical cause, as part of the Child Behavior Checklist (CBCL) Physical problems without known medical cause: Eye problems (not if corrected by glasses) 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 12:23:22.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55035 Child Behavior Checklist (CBCL) - Illness or disability describe text CBCLIllnessDisabilityDescrbTxt The free-text field related to 'Child Behavior Checklist (CBCL) - Illness or disability indicator' for describing the illness or disability, as part of the Child Behavior Checklist (CBCL) The free-text field related to 'Child Behavior Checklist (CBCL) - Illness or disability indicator' for describing the illness or disability, as part of the Child Behavior Checklist (CBCL) Yes-please describe Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 12:00:22.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points 4000

Free-Form Entry

C52261 Child Behavior Checklist (CBCL) - Feels others are out to get them scale CBCLFeelOthrsOutToGetThemScl Scale for whether the child feels others are out to get them, as part of the Child Behavior Checklist (CBCL) Scale for whether the child feels others are out to get them, as part of the Child Behavior Checklist (CBCL) Feels others are out to get him/her 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-23 10:52:32.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52281 Child Behavior Checklist (CBCL) - Showing off or clowning scale CBCLShwOffClownScl Scale for whether the child shows off or clowns, as part of the Child Behavior Checklist (CBCL) Scale for whether the child shows off or clowns, as part of the Child Behavior Checklist (CBCL) Showing off or clowning 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-27 09:54:30.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52038 Child Behavior Checklist (CBCL) - Overweight scale CBCLOverweightScl Scale for whether the child is overweight, as part of the Child Behavior Checklist (CBCL) Scale for whether the child is overweight, as part of the Child Behavior Checklist (CBCL) Overweight 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-20 16:57:47.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55014 Child Behavior Checklist (CBLC) - Respondent school role other text CBLCRespondentSchoolRoleOTH The free-text field related to 'Child Behavior Checklist (CBLC) - Respondent school role type' specifying other text, as part of the Child Behavior Checklist (CBLC) The free-text field related to 'Child Behavior Checklist (CBLC) - Respondent school role type' specifying other text, as part of the Child Behavior Checklist (CBLC) Your role at the school: Other (specify): Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Adult Supplemental 1.00 2017-04-18 11:00:27.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points 255

Free-Form Entry

C52217 Child Behavior Checklist (CBCL) - Clings to adults or too dependent scale CBCLClingAdultTooDependentScl Scale for whether the child clings to adults or is too dependent, as part of the Child Behavior Checklist (CBCL) Scale for whether the child clings to adults or is too dependent, as part of the Child Behavior Checklist (CBCL) Clings to adults or too dependent 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 14:18:30.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55046 Child Behavior Checklist (CBCL) - Overconform rules scale CBCLOverconformRulesScl Scale for the child's tendency to overconform to rules, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to overconform to rules, as part of the Child Behavior Checklist (CBCL) Overconforms to rules 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 12:04:30.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55066 Child Behavior Checklist (CBCL) - Stores up many things describe text CBCLStoreUpManyThingDescribTxt The free-text field related to 'Child Behavior Checklist (CBCL) - Stores up many things scale' for describing the child's tendency to keep unneded things, as part of the Child Behavior Checklist (CBCL) The free-text field related to 'Child Behavior Checklist (CBCL) - Stores up many things scale' for describing the child's tendency to keep unneded things, as part of the Child Behavior Checklist (CBCL) Stores up too many things he/she doesn't need (describe) Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 12:58:28.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points 255

Free-Form Entry

C52295 Child Behavior Checklist (CBCL) - Suspicious scale CBCLSuspcsScl Scale for whether the child is suspicious, as part of the Child Behavior Checklist (CBCL) Scale for whether the child is suspicious, as part of the Child Behavior Checklist (CBCL) Suspicious 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-27 11:27:52.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52089 Child Behavior Checklist (CBCL) - Feels they have to be perfect scale CBCLFeelThyHaveBePrfctScl Scale for whether the child feels they have to be perfect, as part of the Child Behavior Checklist (CBCL) Scale for whether the child feels they have to be perfect, as part of the Child Behavior Checklist (CBCL) Feels he/she has to be perfect 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-21 14:37:57.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55025 Child Behavior Checklist (CBCL) - Behave appropriate relative pupil typical same age code CBLCBhvAptRelPplTypSamAgeCode Code for the appropriateness of the child's behavior relative to typical pupils of the same age, as part of the Child Behavior Checklist (CBCL) Code for the appropriateness of the child's behavior relative to typical pupils of the same age, as part of the Child Behavior Checklist (CBCL) How appropriately is he/she behaving? 4;1;2;3;5;6;7 About average;Much less;Somewhat less;Slightly less;Slightly more;Somewhat more;Much more Numeric Values

Compared to typical pupils of the same age

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 11:40:11.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52244 Child Behavior Checklist (CBCL) - Breaks rules at home, school, or elsewhere scale CBCLBreaksRulesScl Scale for whether the child breaks rules at home, school, or elsewhere, as part of the Child Behavior Checklist (CBCL) Scale for whether the child breaks rules at home, school, or elsewhere, as part of the Child Behavior Checklist (CBCL) Breaks school rules 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 16:16:24.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55057 Child Behavior Checklist (CBCL) - Disrupt class discipline scale CBCLDisruptClassDisciplineScl Scale for the child's tendency to disrupt class discipline, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to disrupt class discipline, as part of the Child Behavior Checklist (CBCL) Disrupts class discipline 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 12:57:12.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C17733 Person completing form name PrsnCompletingFormName Name of person completing the form Name of person completing the form This form filled out by: Alphanumeric Adult Supplemental 3.00 2013-08-30 17:06:52.8 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points 255

Free-Form Entry

C52308 Child Behavior Checklist (CBCL) - Unhappy sad depressed scale CBCLUnhppySdDepScl Scale for whether the child isunhappy, sad or depressed, as part of the Child Behavior Checklist (CBCL) Scale for whether the child isunhappy, sad or depressed, as part of the Child Behavior Checklist (CBCL) Unhappy, sad, or depressed 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-27 12:32:31.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52154 Child Behavior Checklist (CBCL) - Feels dizzy or lightheaded scale CBCLFeelDizzyLightheadedScl Scale for whether the child feels dizzy or lightheaded, as part of the Child Behavior Checklist (CBCL) Scale for whether the child feels dizzy or lightheaded, as part of the Child Behavior Checklist (CBCL) Feels dizzy or lightheaded 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 12:46:56.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55036 Child Behavior Checklist (CBCL) - Odd noise in class scale CBCLOddNoiseInClassScl Scale of the child's tendency to make odd noises in class, as part of the Child Behavior Checklist (CBCL) Scale of the child's tendency to make odd noises in class, as part of the Child Behavior Checklist (CBCL) Hums or makes other odd noises in class. 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 12:04:30.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52262 Child Behavior Checklist (CBCL) - Doesn?t seem to feel guilty after misbehaving scale CBCLNoGuiltyAfterMisbehavScl Scale for whether the child doesnt seem to feel guilty after misbehaving, as part of the Child Behavior Checklist (CBCL) Scale for whether the child doesnt seem to feel guilty after misbehaving, as part of the Child Behavior Checklist (CBCL) Doesn't seem to feel guilty after misbehaving 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-23 10:57:25.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52282 Child Behavior Checklist (CBCL) - Too shy timid scale CBCLTooShyTmdScl Scale for whether the child is too shy or timid, as part of the Child Behavior Checklist (CBCL) Scale for whether the child is too shy or timid, as part of the Child Behavior Checklist (CBCL) Too shy or timid 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-27 10:06:29.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C52039 Child Behavior Checklist (CBCL) - Hangs around with others who get in trouble scale CBCLHangWthOthrsGetInTroublScl Scale for whether the child hangs around with others who get in trouble, as part of the Child Behavior Checklist (CBCL) Scale for whether the child hangs around with others who get in trouble, as part of the Child Behavior Checklist (CBCL) Hangs around with others who get in trouble 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-20 17:02:12.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55015 Child Behavior Checklist (CBLC) - Know child month duration CBLCKnowChildMonthDur Duration in months for which the respondent has known the child, as part of the Child Behavior Checklist (CBLC) Duration in months for which the respondent has known the child, as part of the Child Behavior Checklist (CBLC) For how many months have you known this pupil? Numeric Values Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Adult;Pediatric Supplemental 1.00 2017-04-18 11:06:20.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Free-Form Entry

Months
C52219 Child Behavior Checklist (CBCL) - Lying or cheating scale CBCLLyingCheatingScl Scale for whether the child lies or cheats, as part of the Child Behavior Checklist (CBCL) Scale for whether the child lies or cheats, as part of the Child Behavior Checklist (CBCL) Lying or cheating 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2016-12-22 14:20:38.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

C55047 Child Behavior Checklist (CBCL) - Difficulty learn scale CBCLDifficultyLearnScl Scale for the child's tendency to have difficulty learning, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to have difficulty learning, as part of the Child Behavior Checklist (CBCL) Has difficulty learning 0;1;2 Not True (as far as you know);Somewhat or Sometimes True;Very True or Often True Numeric Values

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 andser all the items as well as you can, even if some do not seem to apply to this pupil.

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Supplemental 1.00 2017-04-18 12:04:30.0 Child Behaviors Checklist (CBCL) Teacher Report Form for Ages 6-18 Psychiatric and Psychological Status Outcomes and End Points

Single Pre-Defined Value Selected

CSV