For office use only

Please print CAREGIVER-TEACHER REPORT FORM FOR AGES 1½-5 ID #

CHILD’S First Middle Last PARENTS’ USUAL TYPE OF WORK, even if not working now.
FULL NAME Please be specific — for example, auto mechanic, high school teacher,
homemaker, laborer, lathe operator, shoe salesman, army sergeant.
CHILD’S GENDER CHILD’S AGE CHILD’S ETHNIC
PARENT 1
 Boy  Girl GROUP (or MOTHER) ___________________________________________
OR RACE
PARENT 2
TODAY’S DATE CHILD’S BIRTHDATE (or FATHER) ____________________________________________
Mo. ____ Day ____ Year _____ Mo. ____ Day ____ Year _____ THIS FORM FILLED OUT BY: (print your full name)
Please fill out this form to reflect your view of the child’s _______________________________________________________
behavior even if other people might not agree. Feel free to Your role at the school or care facility:
write additional comments beside each item and in the space
 primarily educational (teacher)  primarily care (caregiver)
provided on page 2. Be sure to answer all items.
Your training for this position: ________________________________
Name & address of school or care facility: _____________
________________________________________________________
___________________________________________________________
Your experience in child care or early education: ________ years.

I. What kind of a facility is it? (Please be specific, e.g., home day care, day care center, nursery school, preschool, school readiness

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class, Early Childhood Special Education, Headstart, Kindergarten, etc.)________________________________________ __

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II. What is the average number of children in the child’s group or class? _________children in the child’s group or class.
III. How many hours per week does this child spend at the facility? _________hours per week.
IV. For how many months have you known this child? _________months.
V. How well do you know him/her? 1.  Not well 2.  Moderately well 3.  Very well
VI. Has he/she ever been referred for a special education program or special services?

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 Don’t know 0.  No 1.  Yes – what kind and when?

Below is a list of items that describe children. For each item that describes the child now or within the past 2 months,
please circle the 2 if the item is very true or often true of the child. Circle the 1 if the item is somewhat or sometimes

0 1 2
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true of the child. If the item is not true of the child, circle the 0. Please answer all items as well as you can, even if some
do not seem to apply to the child.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True
1. Aches or pains (without medical cause; do not 0 1 2
2 = Very True or Often True
22. Cruelty, bullying, or meanness to others
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include stomach or headaches) 0 1 2 23. Doesn’t answer when people talk to him/her
0 1 2 2. Acts too young for age 0 1 2 24. Difficulty following directions
0 1 2 3. Afraid to try new things 0 1 2 25. Doesn’t get along with other children
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0 1 2 4. Avoids looking others in the eye

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0 1 2 26. Doesn’t know how to have fun; acts like a
0 1 2 5. Can’t concentrate, can’t pay attention for long little adult
0 1 2 6. Can’t sit still, restless or hyperactive 0 1 2 27. Doesn’t seem to feel guilty after misbehaving
0 1 2 7. Can’t stand having things out of place 0 1 2 28. Disturbs other children
0 1 2 8. Can’t stand waiting; wants everything now 0 1 2 29. Easily frustrated
0 1 2 9. Chews on things that aren’t edible 0 1 2 30. Easily jealous
0 1 2 10. Clings to adults or too dependent 0 1 2 31. Eats or drinks things that are not food – do not
0 1 2 11. Constantly seeks help include sweets (describe):__________________

0 1 2 12. Apathetic or unmotivated _______________________________________

0 1 2 13. Cries a lot 0 1 2 32. Fears certain animals, situations, or places other
0 1 2 14. Cruel to animals than daycare or school (describe): ___________

0 1 2 15. Defiant _______________________________________

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0 1 2 16. Demands must be met immediately _______________________________________

0 1 2 17. Destroys his/her own things 0 1 2 33. Feelings are easily hurt
0 1 2 18. Destroys property belonging to others 0 1 2 34. Gets hurt a lot, accident-prone
0 1 2 19. Daydreams or gets lost in his/her thoughts 0 1 2 35. Gets in many fights
0 1 2 20. Disobedient 0 1 2 36. Gets into everything
0 1 2 21. Disturbed by any change in routine 0 1 2 37. Gets too upset when separated from parents

Copyright 1997 T. Achenbach Be sure you have answered all items. Then see other side.
ASEBA, University of Vermont, 1 S. Prospect St., Burlington, VT 05401-3456
Web: www.aseba.org UNAUTHORIZED REPRODUCTION IS ILLEGAL 6-23-14 Edition-901
 Please print your answers. Be sure to answer all items.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True
0 1 2 38. Explosive and unpredictable behavior 0 1 2 71. Shows little interest in things around him/her
0 1 2 39. Headaches (without medical cause) 0 1 2 72. Shows too little fear of getting hurt
0 1 2 40. Hits others 0 1 2 73. Too shy or timid
0 1 2 41. Holds his/her breath 0 1 2 74. Not liked by other children
0 1 2 42. Hurts animals or people without meaning to 0 1 2 75. Overactive
0 1 2 43. Looks unhappy without good reason 0 1 2 76. Speech problem (describe): ________________
0 1 2 44. Angry moods _______________________________________
0 1 2 45. Nausea, feels sick (without medical cause) 0 1 2 77. Stares into space or seems preoccupied
0 1 2 46. Nervous movements or twitching (describe): 0 1 2 78. Stomachaches or cramps (without medical
______________________________________ cause)
______________________________________ 0 1 2 79. Overconforms to rules
0 1 2 47. Nervous, highstrung, or tense 0 1 2 80. Strange behavior (describe): _______________
0 1 2 48. Fails to carry out assigned tasks _______________________________________
0 1 2 49. Fears daycare or school 0 1 2 81. Stubborn, sullen, or irritable

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0 1 2 50. Overtired 0 1 2 82. Sudden changes in mood or feelings

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0 1 2 51. Fidgets 0 1 2 83. Sulks a lot
0 1 2 52. Gets teased by other children 0 1 2 84. Teases a lot
0 1 2 53. Physically attacks people 0 1 2 85. Temper tantrums or hot temper
0 1 2 54. Picks nose, skin, or other parts of body 0 1 2 86. Too concerned with neatness or cleanliness
(describe): _____________________________ 0 1 2 87. Too fearful or anxious

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______________________________________ 0 1 2 88. Uncooperative
0 1 2 55. Plays with own sex parts too much 0 1 2 89. Underactive, slow moving, or lacks energy
0 1 2 56. Poorly coordinated or clumsy 0 1 2 90. Unhappy, sad, or depressed
0

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2

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57. Problems with eyes without medical cause
(describe): _____________________________
______________________________________
58. Punishment doesn’t change his/her behavior
0
0
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91. Unusually loud
92. Upset by new people or situations
(describe): ______________________________
_______________________________________
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0 1 2 59. Quickly shifts from one activity to another 0 1 2 93. Vomiting, throwing up (without medical cause)
0 1 2 60. Rashes or other skin problems (without 0 1 2 94. Unclean personal appearance
medical cause) 0 1 2 95. Wanders away
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0 1 2 61. Refuses to eat 0 1 2 96. Wants a lot of attention

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0 1 2 62. Refuses to play active games 0 1 2 97. Whining

0 1 2 63. Repeatedly rocks head or body 0 1 2 98. Withdrawn, doesn’t get involved with others
0 1 2 64. Inattentive, easily distracted 0 1 2 99. Worries
0 1 2 65. Lying or cheating 100. Please write in any problems the child has that
0 1 2 66. Screams a lot were not listed above.
0 1 2 67. Seems unresponsive to affection 0 1 2 _______________________________________
0 1 2 68. Self-conscious or easily embarrassed 0 1 2 _______________________________________
0 1 2 69. Selfish or won’t share 0 1 2 _______________________________________
0 1 2 70. Shows little affection toward people Please be sure you answered all items.
Underline any you are concerned about.
Does the child have any illness or disability (either physical or mental)? No Yes—Please describe:
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What concerns you most about the child?

Please describe the best things about the child:

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