CDE Detailed Report

Disease: Sport Related Concussion
Subdomain Name: Behavioral Function
CRF: Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18

Displaying 1 - 50 of 174
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
C55070 Child Behavior Checklist (CBCL) - Tardiness scale CBCLTardinessScl Scale for the child's tendency to be tardy to school or class, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to be tardy to school or class, as part of the Child Behavior Checklist (CBCL) Tardy to school or 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 Exploratory 1.00 2016-12-22 12:57:12.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52300 Child Behavior Checklist (CBCL) - Teases a lot scale CBCLTsALotScl Scale for whether the child teases a lot, as part of the Child Behavior Checklist (CBCL) Scale for whether the child teases a lot, as part of the Child Behavior Checklist (CBCL) Teases 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 Exploratory 1.00 2016-12-27 11:56:08.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52093 Child Behavior Checklist (CBCL) - Fear certain animal situation place other than school scale CBCLFearsAnimalSituatnPlaceScl Scale for whether the child fears certain animals, situations, or places, other than school, as part of the Child Behavior Checklist (CBCL) Scale for whether the child fears certain animals, situations, or places, other than school, as part of the Child Behavior Checklist (CBCL) Fears certain animals, situations, or places other than school 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 Exploratory 1.00 2016-12-21 16:10:24.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55029 Child Behavior Checklist (CBCL) - Achievement test most recent subject text CBCLAchvmntTestMstRcntSbjctTxt The free-text field related to 'Child Behavior Checklist (CBCL) - Achievement test most recent name' for specifying the subject of the named achievement test, as part of the Child Behavior Checklist (CBCL) The free-text field related to 'Child Behavior Checklist (CBCL) - Achievement test most recent name' for specifying the subject of the named achievement test, as part of the Child Behavior Checklist (CBCL) Subject Alphanumeric

Most recent achievement test scores (optional)

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Exploratory 1.00 2017-04-18 11:49:33.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 255

Free-Form Entry

C52251 Child Behavior Checklist (CBCL) - Poor school work scale CBCLPoorSchoolWorkScl Scale for whether the child does poor school work, as part of the Child Behavior Checklist (CBCL) Scale for whether the child does poor school work, as part of the Child Behavior Checklist (CBCL) Poor school work 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 Exploratory 1.00 2016-12-22 17:00:09.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55061 Child Behavior Checklist (CBCL) - Behave irresponsible describe text CBCLBehavIresponsibleDescrbTxt The free-text field related to 'Child Behavior Checklist (CBCL) - Behave irresponsible scale' for describing the child's tendency to behave irresponsibly, as part of the Child Behavior Checklist (CBCL) The free-text field related to 'Child Behavior Checklist (CBCL) - Behave irresponsible scale' for describing the child's tendency to behave irresponsibly, as part of the Child Behavior Checklist (CBCL) Behaves irresponsibly (describe) Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Exploratory 1.00 2016-12-22 12:57:12.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 255

Free-Form Entry

C52006 Child Behavior Checklist (CBCL) - Prefer being with younger kid scale CBCLPreferBeWithYoungerKidsScl Scale for whether the child Prefers being with younger kids, as part of the Child Behavior Checklist (CBCL) Scale for whether the child Prefers being with younger kids, as part of the Child Behavior Checklist (CBCL) Prefers being with younger children 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 Exploratory 1.00 2016-12-20 13:39:37.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52316 Child Behavior Checklist (CBCL) - Withdrawn does not get involved scale CBCLWthdrwnDsntGtInvOthScl Scale for whether the child is withdrawn, doesn't give involved with others, as part of the Child Behavior Checklist (CBCL) Scale for whether the child is withdrawn, doesn't give involved with others, as part of the Child Behavior Checklist (CBCL) Withdrawn, doesn't get involved 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 Exploratory 1.00 2016-12-27 13:11:42.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52192 Child Behavior Checklist (CBCL) - Cruelty, bullying, or meanness to others scale CBCLCrueltyBullyMeanToOthrsScl Scale for whether the child displays cruelty, bullying, or meanness to others, as part of the Child Behavior Checklist (CBCL) Scale for whether the child displays cruelty, bullying, or meanness to others, as part of the Child Behavior Checklist (CBCL) Cruelty, bullying, or meanness to 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 Exploratory 1.00 2016-12-22 13:41:56.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55040 Child Behavior Checklist (CBCL) - Fidget scale CBCLFidgetScl Scale of the child's tendency to fidget, as part of the Child Behavior Checklist (CBCL) Scale of the child's tendency to fidget, as part of the Child Behavior Checklist (CBCL) Fidgets 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 Exploratory 1.00 2017-04-18 12:04:30.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52271 Child Behavior Checklist (CBCL) - Refuses to talk scale CBCLRefuseToTalkScl Scale for whether the child refuses to talk, as part of the Child Behavior Checklist (CBCL) Scale for whether the child refuses to talk, as part of the Child Behavior Checklist (CBCL) Refuses to talk 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 Exploratory 1.00 2016-12-23 11:35:43.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52289 Child Behavior Checklist (CBCL) - Stores up many things scale CBCLStrUpMnyThngScl Scale for whether the child stores up too many things he/she doesn't need, as part of the Child Behavior Checklist (CBCL) Scale for whether the child stores up too many things he/she doesn't need, as part of the Child Behavior Checklist (CBCL) Stores up too many things he/she doesn't need 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 Exploratory 1.00 2016-12-27 10:43:23.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52065 Child Behavior Checklist (CBCL) - Nervous movements or twitching scale CBCLNervousMovemenTwitchScl Scale for whether the child makes nervous movements or twitches, as part of the Child Behavior Checklist (CBCL) Scale for whether the child makes nervous movements or twitches, as part of the Child Behavior Checklist (CBCL) Nervous movements or twitching 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 Exploratory 1.00 2016-12-21 11:52:01.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55019 Child Behavior Checklist (CBLC) - Child referral education assistance code CBLCChildRefrlEductnAsstncCode Code for whether, to the respondent's knowledge, the child has ever been referred for educational assistance outside of a regular classroom, such as special class placement, services, or tutoring, as part of the Child Behavior Checklist (CBLC) Code for whether, to the respondent's knowledge, the child has ever been referred for educational assistance outside of a regular classroom, such as special class placement, services, or tutoring, as part of the Child Behavior Checklist (CBLC) Has he/she ever been referred for special class placement, services, or tutoring? Don't know;0;1 Don't know;No;Yes—what kind and when? 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 Exploratory 1.00 2017-04-18 11:15:38.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52237 Child Behavior Checklist (CBCL) - Fears they might think or do something bad scale CBCLFearThinkDoBadThingScl Scale for whether the child fears they might think or do something bad, as part of the Child Behavior Checklist (CBCL) Scale for whether the child fears they might think or do something bad, as part of the Child Behavior Checklist (CBCL) Fears he/she might thing or do something bad 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 Exploratory 1.00 2016-12-22 14:57:56.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55051 Child Behavior Checklist (CBCL) - Stomachache no known medical cause scale CBCLStmchachNoKnwnMdclCausScl Scale for whether the child has stomachaches without known medical cause, as part of the Child Behavior Checklist (CBCL) Scale for whether the child has stomachaches without known medical cause, as part of the Child Behavior Checklist (CBCL) Physical problems without known medical cause: Stomachaches 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 Exploratory 1.00 2016-12-22 12:57:12.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55071 Child Behavior Checklist (CBCL) - Fail perform assigned task scale CBCLFailPerformAssignTaskScl Scale for the child's tendency to fail to perform assigned tasks, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to fail to perform assigned tasks, as part of the Child Behavior Checklist (CBCL) Fails to carry out assigned tasks 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 Exploratory 1.00 2016-12-22 12:57:12.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52301 Child Behavior Checklist (CBCL) - Temper tantrum hot temper scale CBCLTmprTntrmHtTmprScl Scale for whether the child has temper tantrums or a hot temper, as part of the Child Behavior Checklist (CBCL) Scale for whether the child has temper tantrums or a hot temper, as part of the Child Behavior Checklist (CBCL) Temper tantrums or hot temper 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 Exploratory 1.00 2016-12-27 12:00:41.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52094 Child Behavior Checklist (CBCL) - Gets hurt a lot, accident-prone scale CBCLHurtALotAccidentProneScl Scale for whether the child gets hurt a lot, is accident-prone, as part of the Child Behavior Checklist (CBCL) Scale for whether the child gets hurt a lot, is accident-prone, as part of the Child Behavior Checklist (CBCL) Gets hurt a lot, accident-prone 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 Exploratory 1.00 2016-12-21 16:13:08.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55030 Child Behavior Checklist (CBCL) - Achievement test most recent date CBCLAchvmntTestMstRcntDate The field related to 'Child Behavior Checklist (CBCL) - Achievement test most recent name' for specifying the date of the named achievement test, as part of the Child Behavior Checklist (CBCL) The field related to 'Child Behavior Checklist (CBCL) - Achievement test most recent name' for specifying the date of the named achievement test, as part of the Child Behavior Checklist (CBCL) Date Date or Date & Time

Most recent achievement test scores (optional)

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

Free-Form Entry

C52252 Child Behavior Checklist (CBCL) - Obsessions scale CBCLObsessionsScl Scale for whether the child can't get their mind off certain thoughts, obsessions, as part of the Child Behavior Checklist (CBCL) Scale for whether the child can't get their mind off certain thoughts, obsessions, as part of the Child Behavior Checklist (CBCL) Can't get his/her mind off certain thoughts' obsessions 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 Exploratory 1.00 2016-12-22 17:07:22.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55062 Child Behavior Checklist (CBCL) - Explosive unpredictable behavior scale CBCLExplsvUnprdctablBehavrScl Scale for the child's tendency to exhibit explosive or unpredictable behavior, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to exhibit explosive or unpredictable behavior, as part of the Child Behavior Checklist (CBCL) Explosive and unpredictable behavior 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 Exploratory 1.00 2016-12-22 12:57:12.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52015 Child Behavior Checklist (CBCL) - Argues a lot scale CBCLArgueALotScl Scale for whether the child argues a lot, as part of the Child Behavior Checklist (CBCL) Scale for whether the child argues a lot, as part of the Child Behavior Checklist (CBCL) Argues 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 Exploratory 1.00 2016-12-20 13:51:27.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52317 Child Behavior Checklist (CBCL) - Worry scale CBCLWorryScl Scale for whether the child worries, as part of the Child Behavior Checklist (CBCL) Scale for whether the child worries, as part of the Child Behavior Checklist (CBCL) Worries 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 Exploratory 1.00 2016-12-27 13:19:50.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52196 Child Behavior Checklist (CBCL) - Poorly coordinated or clumsy scale CBCLPoorCoordinationClumsyScl Scale for whether the child is poorly coordinated or clumsy, as part of the Child Behavior Checklist (CBCL) Scale for whether the child is poorly coordinated or clumsy, as part of the Child Behavior Checklist (CBCL) Poorly coordinated or clumsy 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 Exploratory 1.00 2016-12-22 13:51:42.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55041 Child Behavior Checklist (CBCL) - Destroy property belong others scale CBCLDstryPrprtyBlngOthrScl Scale of the child's tendency to destroy property belonging to others, as part of the Child Behavior Checklist (CBCL) Scale of the child's tendency to destroy property belonging to others, as part of the Child Behavior Checklist (CBCL) Destroys property belonging to 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 Exploratory 1.00 2017-04-18 12:04:30.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52273 Child Behavior Checklist (CBCL) - Overtired without good reason scale CBCLOvertiredNoGoodReasonScl Scale for whether the child gets overtired without good reason, as part of the Child Behavior Checklist (CBCL) Scale for whether the child gets overtired without good reason, as part of the Child Behavior Checklist (CBCL) Overtired without good reason 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 Exploratory 1.00 2016-12-23 11:40:37.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52290 Child Behavior Checklist (CBCL) - Strange behavior scale CBCLStrngBhvrScl Scale for whether the child displays strange behavior, as part of the Child Behavior Checklist (CBCL) Scale for whether the child displays strange behavior, as part of the Child Behavior Checklist (CBCL) Strange behavior 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 Exploratory 1.00 2016-12-27 10:47:05.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52070 Child Behavior Checklist (CBCL) - Best thing description text CBCLBestThingDescTxt description text of the best things about the child, as part of the Child Behavior Checklist (CBCL) description text of the best things about the child, as part of the Child Behavior Checklist (CBCL) Please describe the best things about this pupil: 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 Exploratory 1.00 2016-12-21 11:58:14.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 255

Free-Form Entry

C55020 Child Behavior Checklist (CBLC) - Child referral education assistance describe text CBLCChildRefrlAsstnceDscrbTxt The free-text field related to 'Child Behavior Checklist (CBLC) - Child referral education assistance indicator' for describing educational assistance for which the child was referred, as part of the Child Behavior Checklist (CBLC) The free-text field related to 'Child Behavior Checklist (CBLC) - Child referral education assistance indicator' for describing educational assistance for which the child was referred, as part of the Child Behavior Checklist (CBLC) Yes-what kind and when? 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 Exploratory 1.00 2017-04-18 11:21:12.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 255

Free-Form Entry

C52238 Child Behavior Checklist (CBCL) - Hears sound or voices that arent there description text CBCLHearSoundVoicesNotThereTxt description text of the sounds or voices that aren't there that the child hears, as part of the Child Behavior Checklist (CBCL) description text of the sounds or voices that aren't there that the child hears, as part of the Child Behavior Checklist (CBCL) Hears sounds or voices that aren't there (describe) Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Exploratory 1.00 2016-12-22 15:00:34.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 255

Free-Form Entry

C55052 Child Behavior Checklist (CBCL) - Vomit no known medical cause scale CBCLVomitNoKnwnMdclCausScl Scale for the child's tendency to vomit without known medical cause, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to vomit without known medical cause, as part of the Child Behavior Checklist (CBCL) Physical problems without known medical cause: Vomiting, throwing up 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 Exploratory 1.00 2016-12-22 12:57:12.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C00007 Birth date BirthDate Date (and time, if applicable and known) the participant/subject was born Date (and time, if applicable and known) the participant/subject was born Pupil's Birthdate (if known) Date or Date & Time Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Exploratory 3.00 2013-07-25 08:54:08.2 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Free-Form Entry

793
C55072 Child Behavior Checklist (CBCL) - Overanxious to please scale CBCLOveranxiousToPleaseScl Scale for the child's tendency to be overly anxious/eager to please, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to be overly anxious/eager to please, as part of the Child Behavior Checklist (CBCL) Overly anxious to please 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 Exploratory 1.00 2016-12-22 12:57:12.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52302 Child Behavior Checklist (CBCL) - Thinks about sex too much scale CBCLThnkAbtSxTooMchScl Scale for whether the child thnks about sex too much, as part of the Child Behavior Checklist (CBCL) Scale for whether the child thnks about sex too much, as part of the Child Behavior Checklist (CBCL) Seems preoccupied with sex 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 Exploratory 1.00 2016-12-27 12:07:39.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52095 Child Behavior Checklist (CBCL) - Disobedient at school scale CBCLDisobedientAtSchoolScl Scale for whether the child is disobedient at school, as part of the Child Behavior Checklist (CBCL) Scale for whether the child is disobedient at school, as part of the Child Behavior Checklist (CBCL) Disobedient at school 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 Exploratory 1.00 2016-12-21 16:23:55.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55031 Child Behavior Checklist (CBCL) - Achievement test most recent status CBCLAchvmntTestMstRcntStatus The field related to 'Child Behavior Checklist (CBCL) - Achievement test most recent name' for specifying the status of the child's performance on the named achievement test, as part of the Child Behavior Checklist (CBCL) The field related to 'Child Behavior Checklist (CBCL) - Achievement test most recent name' for specifying the status of the child's performance on the named achievement test, as part of the Child Behavior Checklist (CBCL) Percentile or grade level obtained Alphanumeric

Most recent achievement test scores (optional)

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Exploratory 1.00 2017-04-18 11:49:33.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 50

Free-Form Entry

C52254 Child Behavior Checklist (CBCL) - Nervous movements or twitching description text CBCLNervousMovementTwitchTxt description text of the child's nervous movements or twitches, as part of the Child Behavior Checklist (CBCL) description text of the child's nervous movements or twitches, as part of the Child Behavior Checklist (CBCL) Nervous movements or twitching (describe) Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Exploratory 1.00 2016-12-22 17:13:04.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 255

Free-Form Entry

C55063 Child Behavior Checklist (CBCL) - Easily frustrated scale CBCLEasilyFrustratedScl Scale for the child's tendency to be frustrated easily, as part of the Child Behavior Checklist (CBCL) Scale for the child's tendency to be frustrated easily, as part of the Child Behavior Checklist (CBCL) Demands must be met immediately, easily frustrated 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 Exploratory 1.00 2016-12-22 12:57:12.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52032 Child Behavior Checklist (CBCL) - Acts too young for their age scale CBCLActTooYoungScl Child Behavior Checklist (CBCL) - Acts too young for their age scale Scale for whether the child can't stand waiting, wants everything now, as part of the Child Behavior Checklist (CBCL) Acts too young for his/her age 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 Exploratory 1.00 2016-12-20 15:31:16.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55010 Child Behavior Checklist (CBLC) - Occupation parent 1 type CBLCOccupationParent1Typ Type of occupation of parent 1, as part of the Child Behavior Checklist (CBLC) Type of occupation of parent 1, as part of the Child Behavior Checklist (CBLC) Parent 1 (or Father) Type of Work Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Adult Exploratory 1.00 2017-04-18 10:55:06.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 255

Free-Form Entry

C52198 Child Behavior Checklist (CBCL) - Deliberately harms self or attempts suicide scale CBCLHarmSelfAttemptSuicideScl Scale for whether the child deliberately harms themselves or attempts suicide, as part of the Child Behavior Checklist (CBCL) Scale for whether the child deliberately harms themselves or attempts suicide, as part of the Child Behavior Checklist (CBCL) Deliberately harms self or attempts suicide 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 Exploratory 1.00 2016-12-22 13:54:03.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55042 Child Behavior Checklist (CBCL) - Difficulty follow direction scale CBCLDffcltyFollwDirectnScl Scale of the child's tendency to have difficulty following directions, as part of the Child Behavior Checklist (CBCL) Scale of the child's tendency to have difficulty following directions, as part of the Child Behavior Checklist (CBCL) Difficulty following directions 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 Exploratory 1.00 2017-04-18 12:04:30.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52275 Child Behavior Checklist (CBCL) - Scream a lot scale CBCLScrmAltScl Scale for whether the child screams a lot, as part of the Child Behavior Checklist (CBCL) Scale for whether the child screams a lot, as part of the Child Behavior Checklist (CBCL) Screams 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 Exploratory 1.00 2016-12-23 14:18:59.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52291 Child Behavior Checklist (CBCL) - Strange ideas scale CBCLStrngIdeaScl Scale for whether the child has strange ideas, as part of the Child Behavior Checklist (CBCL) Scale for whether the child has strange ideas, as part of the Child Behavior Checklist (CBCL) Strange ideas 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 Exploratory 1.00 2016-12-27 10:49:39.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C52075 Child Behavior Checklist (CBCL) - Drinks alcohol without parents approval description text CBCLDrinkAlcNoParentApprovTxt description text of the child drinking alcohol without parents' approval, as part of the Child Behavior Checklist (CBCL) description text of the child drinking alcohol without parents' approval, as part of the Child Behavior Checklist (CBCL) Uses alcohol or drugs for nonmedical purposes (don't include tobacco) (describe) Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Exploratory 1.00 2016-12-21 12:07:18.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 255

Free-Form Entry

C55021 Child Behavior Checklist (CBCL) - School grade repeat describe text CBCLSchoolGradRptDscrbTxt The free-text field related to 'School repeat grade indicator' for describing the grade repeated by the child and the reasons for doing so, as part of the Child Behavior Checklist (CBCL) The free-text field related to 'School repeat grade indicator' for describing the grade repeated by the child and the reasons for doing so, as part of the Child Behavior Checklist (CBCL) 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 Exploratory 1.00 2017-04-18 11:23:22.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 255

Free-Form Entry

C52239 Child Behavior Checklist (CBCL) - Cant concentrate, cant pay attention for long scale CBCLNoConcentratPayAttentnScl Scale for whether the child cant concentrate, cant pay attention for long, as part of the Child Behavior Checklist (CBCL) Scale for whether the child cant concentrate, cant pay attention for long, as part of the Child Behavior Checklist (CBCL) Can't concentrate, can't pay attention for long 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 Exploratory 1.00 2016-12-22 15:04:02.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Single Pre-Defined Value Selected

C55053 Child Behavior Checklist (CBCL) - Other physical problems without known medical cause describe text CBCLOthPhyPbmWoKnwMdlCsDscrTxt The free-text field related to 'Child Behavior Checklist (CBCL) - Other physical problems without known medical cause scale' for describing the other physical problems, as part of the Child Behavior Checklist (CBCL) The free-text field related to 'Child Behavior Checklist (CBCL) - Other physical problems without known medical cause scale' for describing the other physical problems, as part of the Child Behavior Checklist (CBCL) Other (describe) Alphanumeric Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Exploratory 1.00 2017-04-18 12:34:25.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points 255

Free-Form Entry

C00008 Age value AgeVal Value for participant's age, calculated as elapsed time since the birth of the participant Value for participant's age, calculated as elapsed time since the birth of the participant Pupil's Age Numeric Values

Record in months

Copyright 2001 T. Achenbach, ASEBA, University of Vermont, 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org Pediatric Exploratory 3.10 2024-02-29 15:47:28.0 Child Behavior Checklist (CBCL) Teacher Report Form for Ages 6-18 Behavioral Function Outcomes and End Points

Free-Form Entry

0 1800 month
CSV