Philippine Early Childhood

Development Checklist

Childs Record Form 2

(3.1 5.11 years old)
Childs Name:

Province: Municipality/City: Barangay:

Sex: Male Female Handedness: Right Left

To the Parents:

The Philippine Early Childhood Development Checklist (Form 2) contains knowledge, skills and attitudes
of children 3.1 to 5.11 years old. This may be used as a guide in knowing your child and consequently
give appropriate care and teaching to guide their growth and development.

Content:

Every page contains dierent domains of development with their corresponding total scores:
Gross Motor Domain has 13 items
Fine Motor Domain has 11 items
Self-Help Domain has 27 items
Receptive Language Domain has 5 items
Expressive Language Domain has 8 items
Cognitive Domain has 21 items
Social-Emotional Domain has 24 items

Each item observed are recorded two times within a school year: (1) at the start, and (2) at the end of
the school year.

Columns:

P Present (the child can do the task)

O Observed (the child was observed doing the task)
R Report given by parents/caregiver about the skill

Score:

( ) Present or child is able to do the task

( - ) Skill is not present or child does not respond
( -9) no opportunity to observe the skill

1
 GROSS MOTOR DOMAIN

SOCIAL - EMOTIONAL MATERIALS/ P O R COMMENTS P O R COMMENTS

DOMAIN PROCEDURE

1. Climbs on chair or Parental report

other elevated piece will suce.
of furniture like a
bed without help

2. Walks backwards MATERIAL: toy

Runs without PROCEDURE:
tripping or falling Ask the child to
walk backwards
by demonstrating
this. Credit
if the child is able
to walk
backwards
without falling
and holding on to
anything.
Parental report
will suce.

3. Walks downstairs, MATERIAL: ball

2 feet on each step, PROCEDURE:
with one hand held Encourage the
child to run
by rolling a ball
across the
floor. Credit if
the child can run
fast and smoothly
without tripping
or falling.

4. Walks upstairs Automatically

holding handrail, 2 credit if item #6 is
feet on each step passed.
Parental report
will suce.

5. Walks upstairs MATERIAL: toy

with alternate feet PROCEDURE:
without holding Place a toy in the
handrail middle
of the 4th or 5th
step and ask the
child to walk up
the stairs to get
the toy. Credit if
the child walks up
the stairs using
the handrail or

2
 SOCIAL - EMOTIONAL MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

wall for support

and places both
feet on each step
before stepping
on the next one.
Automatically
credit if item #6 is
passed.
Parental report
will suce.

6. Walks downstairs MATERIAL: toy

with alternate feet PROCEDURE:
without holding Place a toy in the
handrail middle of
the 4th or 5th step
and ask the child
to walk upstairs
to get the toy.
Credit if the child
walks upstairs,
alternating his
feet as he steps
on each
successive step
without
holding onto the
handrail
or wall for
support.
Parenting report
will suce.

7. Moves body part as MATERIAL: TOY

directed PROCEDURE:
Place a toy at
the bottom of
the stairs and
ask the child to
walk downstairs
to get the toy.
Credit if the child
walks downstairs,
alternating
his feet as he
steps on each
successive step
without holding
onto the handrail
or wall for
support. Do not
give credit if the
child places both

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 SOCIAL - EMOTIONAL MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

feet on the step or

uses the handrail
or wall for
support.
Parental report
will suce.

8. Jumps up PROCEDURE:
Ask the child to
raise both
arms.
This must be
elicited by the
interviewer.

9. Throws ball MATERIAL: ball

overhead with PROCEDURE:
direction Give the child the
ball and stand at
least 3 feet away
from him. Ask the
child to throw the
ball to you using
an overhand
throw. You may
show the child
how to do it.
Credit if the child
throws the ball
within your arms
reach between
your knees and
head using an
overhand
throw and not
sideways or
underhand.

10. Hops 3 steps on PROCEDURE:

preferred foot Ask the child
to lift his foot
and hop at least
3 times on his
preferred foot.
Credit if the child
is able to hop at
least 3 times on
his preferred foot
without holding
on to anything.

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 SOCIAL - EMOTIONAL MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

11. Jumps and turns PROCEDURE:

Ask the child to
jump while
making a half-
turn. Credit
if the child is able
to do this without
tripping or falling.

12. Dances patterns/ Parental report

joins group will suce.
movement
activities

TOTAL SCORE

FINE MOTOR DOMAIN

FINE MOTOR MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

1. Uses all 5 fingers MATERIAL: small

to get food/toys toy/object
placed on a flat PROCEDURE:
surface Seat the child on
the parents lap
with his elbows at
level with the
tabletop and
his hands on
the table or flat
surface.
Drop a small
toy in front of
him and attract
his attention by
pointing to the
toy or tapping the
table/ flat surface.
Credit if the
child picks up
the toy, using
all 5 fingers as if
raking.
Automatically
credit if he passes
the next item.

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 FINE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

2. Picks up objects MATERIAL: any

with thumb and small toy or food
index finger PROCEDURE:
Place a toy/food
in front of the
child and within
his reach. Attract
his attention
by tapping near
the toy/ food.
Credit if the child
uses the tips of his
thumb and
index or forefinger
to pick
up the toy/food.

3. Displays a definite MATERIAL: toy

hand preference PROCEDURE:
Place the toy
directly in front
of the child at
midline (not to his
left or his right)
and ask him to
reach for this.
Credit if he uses
the same hand 2
out of 3 times.
Parental report
will suce.

4. Puts small objects MATERIAL: small

in/out of containers objects, container
This must be
elicited by the
interviewer.

5. Holds crayon with MATERIAL:

all the fingers of crayon
his hand as though PROCEDURE:
making a fist (i.e., Present the child
palmar grasp) with a crayon and
have him get this.
Credit if he holds
it by wrapping all
5 fingers around
as if making a fist.
Automatically
credit this item if
he uses the tips of
all 5 fingers or his
thumb, index and

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 FINE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

middle fingers.
This must be
elicited by
the interviewer.

6. Unscrews lid MATERIAL:

of container or Container with
unwraps food screw-on top or
wrapped candy.
This must be
elicited by the
interviewer.

7. Scribbles MATERIALS: paper,

spontaneously pencil/crayon
PROCEDURE:
Place a paper and
pencil/ crayon on
the table and ask
the child to draw
anything he wants
without showing
him what to do.
Credit if the child
uses the tips of
his thumb and
any of his other
fingertips to grasp
the pencil/crayon
and purposefully
scribbles on
the paper (not
accidentally).

8. Scribbles vertical MATERIALS: paper,

and horizontal lines pencil/ crayon
PROCEDURE:
Place a paper and
pencil/ crayon on
the table or
flat surface and
ask the child to
draw vertical and
horizontal lines
after you have
demonstrated
these to him.
Credit if the child
produces a vertical
or horizontal line
that is at least 2
inches long and
does not deviate

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 FINE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

or vary from your

vertical line by
more than 30
degrees. The
lines may be wavy
but not broken.

9. Draws a human MATERIALS:

figure (head, paper, pencil
eyes, trunk, arms, PROCEDURE:
hands/ fingers) Give the child a
pencil and
a paper and ask
him to draw
a picture of a
person.
Credit if the
child has drawn
3 or more body
parts. A pair is
considered one
part (eyes, ears,
arms, hands, legs,
and feet) and
must be drawn
in pairs to get
full credit unless
the drawing is in
profile

10. Draws a house MATERIALS:

using geometric paper, pencil
forms PROCEDURE:
Give the child a
pencil and paper
and ask him to
draw a picture of
a house. Credit
if the child has
drawn at least the
roof, main frame,
and a door or
window.

TOTAL SCORE

8
 SELF-HELP DOMAIN

SELF-HELP MATERIALS/ P O R COMMENTS P O R COMMENTS

DOMAIN PROCEDURE

Feeding sub-domain

1. Feeds self with MATERIALS:

finger foods (e.g. bread, biscuits
biscuits, bread) This must be
using fingers elicited by the
interviewer.

2. Feeds self using Automatically

fingers to eat rice/ credit if the child
viands with spillage eats without
spillage.
Parental report
will suce.

3. Feeds self using Automatically

spoon with spillage credit if the child
eats without
spillage.

4. Feeds self using Parental report

fingers without will suce.
spillage

5. Feeds self using Parental report

spoon without will suce.
spillage

6. Eats without need Parental report

for spoonfeeding will suce.
during any meal

7. Helps hold cup for Parental report

drinking will suce

8. Drinks from cup with MATERIALS:

spillage drinking cup,
water
Note: The cup
should not have a
lid or spout.
This must be
elicited by the
interviewer.

9. Drinks from cup MATERIALS:

unassisted drinking cup,
water
Note: The cup
should not have a
lid or spout.

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 SELF-HELP MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

This must be
elicited by the
interviewer.
Automatically
credit if he passes
the next item.

10. Pours from pitcher MATERIALS:

without spillage drinking cup,
water
This must be
elicited by the
interviewer.
Parental report
will suce.

11. Prepares own Ask the caregiver

food/snack if the child can
prepare his own
snack without
help except for
getting items that
are hard to reach
(e.g. bowl spoon).

12. Prepares meals for Parental report

younger siblings/ will suce.
family members
when no adult is
around

Dressing sub-domain

13. Participates when Parental report

being dressed will suce.
(e.g. raises arms or
lifts leg)

14. Pulls down gartered Parental report

short pants will suce.

15. Removes sando Parental report

will suce.

16. Dresses without Parental report

assistance except for will suce.
buttoning and tying

17. Dresses without MATERIAL: small

assistance, including shirt with button
buttoning and tying and shoestring
PROCEDURE:
Have the child

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 SELF-HELP MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

demonstrate how
to button and tie
to credit this item.

Toilet training sub-domain

18. Informs the adult Parental report
only after he has will suce.
already urinated
(peed) or moved
his bowels
(poohed) in his
underpants

19. Informs adult of Parental report

need to urinate will suce.
(pee) or move
bowels (pooh-
pooh) so he can
be brought to a
designated
place (e.g.,
comfort room)

20. Goes to the Parental report

designated place will suce.
to urinate (pee)
or move bowels
(pooh) but
sometimes still
does this in his
underpants

21. Goes to the Parental report

designated place will suce.
to urinate (pee)
or move bowels
(pooh) and
never does this
is his underpants
anymore

22. Wipes/Cleans Parental report

self after a bowel will suce.
movement (pooh)

11
 SELF-HELP MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

Bathing sub-domain

23. Participates when Parental report

bathing (e.g. will suce.
rubbing arms
with soap)

24. Washes and dries Ask the caregiver

hands without if the child can
any help wash and dry
his face without
any help or
supervision
except to turn on/
o faucets that
are out of reach.

25. Washes face Ask the caregiver

without any help if the child can
wash and dry
his face without
any help or
supervision
except to turn on/
o faucets that
are out of reach.

26. Bathes without Parental report

any help will suce.

TOTAL SCORE

RECEPTIVE LANGUAGE DOMAIN

RECEPTIVE LANGUAGE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

1. Points to family PROCEDURE:

member when Ask the child to
asked to do so point to his
mother/caregiver.
Credit if he does
so.

2. Points to 5 body PROCEDURE:

parts on himself Have the child
when asked to do point to his
so eyes, nose,

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 RECEPTIVE LANGUAGE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

mouth, hands
and feet. Credit if
he can point to all
of these.

3. Points to 5 named MATERIAL: picture

pictured objects book 1
when asked to do PROCEDURE:
so Show the child
a picture book
(2 picture per
page) and ask him
to point to the
picture by saying
Wheres
the____?
Credit if the child
can use his finger
to point to at
least 5 pictures.

4. Follows one-step MATERIALS: block/

instructions that toy
include simple PROCEDURE:
prepositions (e.g., Ask the child to
in, on, under, etc.) put a block/toy
under the table;
on the table; in the
bag. Do not point
or use gestures
when giving the
instructions. Credit
if the child is able
to follow at least
one of the
instructions.

5. Follows 2-step MATERIALS: block/
instructions that toy PROCEDURE:
include simple Ask the child to
prepositions get a block/toy
from under the
table and then
place it on the
table. Do not point
or use gestures
when giving the
instruction.
Credit if the child is
able to follow.

TOTAL SCORE

13
 EXPRESSIVE LANGUAGE DOMAIN

EXPRESSIVE LANGUAGE MATERIALS/ P O R COMMENTS P O R COMMENTS

DOMAIN PROCEDURE

1. Uses 5 - 20 PROCEDURE:
recognizable words Ask the caregiver
if the child can
clearly say 5 to 6
words aside from
mama and
papa. This will
be the minimum
number.

2. Uses pronouns (e.g. Parental report

I, me, ako, akin) will suce.

3. Uses 2- to 3-word Parental report

verb-noun will suce.
combinations
(e.g. hingi gatas)

4. Names objects in MATERIALS:

pictures picture book 2
PROCEDURE:
Show the child
a picture book,
point to an object
in the book, then
ask him to
name it (e.g.,
Ano ito?).
Credit if the
child can say the
correct name of
at least 4 objects.

5. Speaks in Parental report

grammatically will suce.
correct 2- to 3- word
sentences

6. Asks what Parental report

questions will suce.

7. Asks who and Parental report

why questions will suce.

8. Gives account of PROCEDURE:

recent experiences Ask the caregiver
(with prompting) in if the child can
order of occurrence recount recent
using past tense experiences in
correct sequence

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 EXPRESSIVE LANGUAGE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

and using past

tenses correctly.
The caregiver can
prompt him
so he can
complete what
he is talking about
(e.g., tapos, ano
pang nangyari)
Parental report
will suce.

TOTAL SCORE

COGNITIVE DOMAIN

COGNITIVE MATERIALS/ P O R COMMENTS P O R COMMENTS

DOMAIN PROCEDURE

1. Looks at direction of MATERIALS:

a fallen object spoon /ball
PROCEDURE:
With the child
seated, get His
attention and
drop a spoon/ball
in front of him.
Then observe
if his eyes look
down as it falls.
Credit if the child
can bring his
eyes and head
down as the
object falls.
Automatically
credit if item #5 is
passed.

2. Looks for a partially MATERIALS: ball,

hidden object small towel/cloth
PROCEDURE:
With the child
facing you,
partially hide
a ball behind a
small towel and
observe if he will

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 COGNITIVE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

look for it and

find it. Credit if
the child pulls the
towel and gets
the hidden ball.
Automatically
credit if item #5 is
passed.

3. Imitates behavior Automatically

just seen a few credit if item #6 is
minutes earlier passed.
Parental report
will suce.

4. Offers on object but Parental report

may not release it will suce.

5. Looks for completely MATERIALS: ball,

hidden object small towel/cloth
PROCEDURE:
With the child
facing you,
hide a ball
completely under
a small towel and
observe if he will
look under the
towel. Credit if he
looks under the
towel and gets
the hidden ball.

6. Exhibits simple MATERIALS: doll

pretend play or toy car/
(feeds, puts doll to block
sleep) PROCEDURE:
If the child is a
girl, carry the doll
and pretend to
rock it to sleep. If
the child is a boy,
move the toy
car/block back
and forth.
Credit if the child
can imitate this.

7. Matches objects MATERIALS: pairs

of spoons, balls,
blocks
PROCEDURE:
Place 1 spoon, 1

16
 COGNITIVE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

ball, and 1 block

on the table.
Give the child
the other set of
objects arranged
in random order.
Demonstrate
a matching,
response (e.g.
spoon to spoon)
then return the
objects to the
child. Say, Put
each object on
the one that is
just like it. Credit
if the child can
match the
objects correctly.

8. Matches 2 to 3 MATERIALS: 3
colors pairs of crayons
(blue, red, yellow)
PROCEDURE:
Place 1 crayon
of each color on
the table or flat
surface. Give the
child the other
crayons arranged
in random order.
Demonstrate
a matching
response (e.g.,
red crayon with
another red
crayon) then
return the
crayons to the
child. Say,
Put each crayon
on the one that is
just like it. Credit
if the child can
match all colors
correctly.

9. Matches pictures MATERIALS:

3 pairs of
picture cards
(e.g., pictures
of an apple,
orange, banana)

17
 COGNITIVE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

PROCEDURE:
Place one copy of
each picture on
the table or flat
surface. Give the
child the other
pictures arranged
in random order.
Demonstrate
a matching
response (e.g.,
picture of an
apple with
another apple)
then return the
pictures to the
child. Say, Put
each picture on
the one that is
just like it.
Credit if the child
can match all the
pictures correctly.

10. Sorts based on MATERIALS: 4

shapes pairs of dierent
shapes that are
of the same
size and color.
PROCEDURE:
Show the child
the shapes. Tell
the child, Put
together the
ones that are
the same. After
the child sorts
and groups the
shapes, point to
the ones with
the same shape
and ask. Why
did you put these
together? Credit
if the child can
group the same
shapes and say
why they
are the same
(pareho sila,
pareho sila ng
hugis/ shape,
puro sila bilog).

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 COGNITIVE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

11. Sorts objects based MATERIALS: 4

on 2 attributes pairs of the same
(e.g., size and color) shape that dier
in size and color:
2 sizes, 2 colors
PROCEDURE:
Show the child
the shapes.
Tell the child,
Put together
the ones that are
the same.
Credit if the child
can sort allthe
shapes according
to size and color.

12. Arranges objects MATERIALS:

according to size 4 pieces of
from smallest to graduated
biggest sized squares
and 4 pieces of
graduated sized
circles
PROCEDURE:
Show the child
the first set
of squares spread
out at random on
a table or flat
surface. Say,
Here are 4
squares. Look, I
can begin with
the smallest,
then move to
the next big one,
until I reach the
biggest one.
Demonstrate how
to arrange the
squares. Then
disarrange these
and tell the child.
Now you start
with the smallest,
put to the next
one and the next
big one until the
last one. Repeat
this procedure
using the

19
 COGNITIVE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

circles without
demonstrating.
Credit if the child
arranges
at least one set of
shapes in
correct order
from smallest
to biggest. Allow
one trial for each
set of shapes.

13. Names 4 to 6 colors MATERIALS:

6 papers of
dierent colors
PROCEDURE:
Ask the child,
What color is
this? Credit if the
child can name
4 to 6 colors
correctly.

14. Copies shapes MATERIALS:

Paper and pen/
crayon
PROCEDURE: Let
the child copy a
circle, triangle,
and square after
demonstrating
how each of
these is done.

15. Names 3 animals Credit if the child

or vegetables when can name
asked 3 animals or
vegetables.

16. States what common Credit if he can

household items are state the use of
used for function of at
least 2 household
items like a bed
and a drinking
glass.

17. Can assemble simple MATERIAL: simple

puzzles 4- to 6- piece
puzzles
Procedure: Allow
the child to solve
the puzzle in 2

20
 COGNITIVE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

minutes. Proceed
to the next item
after 2 minutes.

18. Demonstrates an Credit if the

understanding child can give an
of opposites by opposite word.
completing a
statement
(e.g., Ang aso ay
malaki, ang daga
ay__________)

19. Points to left and PROCEDURE: Sit

right sides of body across the child
and ask Show me
your left hand.
Do the same for
the following:
Right hand, left
foot, right knee,
left shoulder, right
eye, right knee,
left leg. Credit
if the child can
correctly point out
the left and right
side on at least
5 body parts as
requested.

20. Can state what MATERIALS: 2

is silly or wrong picture cards
with pictures (e.g. depicting activities
Ano ang mali sa that have
larawang ito?) something silly or
wrong with them.
PROCEDURE:
Show the pictured
scenes to the child
one at a time and
ask, What is
wrong with this
picture? Credit if
the child correctly
identifies what
made the picture
incorrect.

21. Matches upper and MATERIALS: 2 sets

lower case letters of alphabet cards
with upper and
lower case letters

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 COGNITIVE MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

PROCEDURE:
Randomly
present 4 pairs
of upper case
letters. Have
the child match
these. Do the
same with 4 pairs
of lower case
letters. Credit
if the child can
match any 4
pairs, regardless
of whether these
are the upper or
lower case.
Note: The child
does not have to
know the names
of the letters.

TOTAL SCORE

SOCIAL-EMOTIONAL DOMAIN

SOCIAL-EMOTIONAL MATERIALS/ P O R COMMENTS P O R COMMENTS

DOMAIN PROCEDURE

1. Enjoys watching Parental report

activities of nearby will suce.
people or animals

2. Friendly with Parental report

strangers but initially will suce.
may show slight
anxiety or shyness

3. Plays alone but likes Parental report

to be near familiar will suce.
adults or brothers
and sisters

4. Laughs or squeals Parental report

aloud in play will suce.

5. Plays peek-a-boo Parental report

(bulaga) will suce

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 SOCIAL-EMOTIONAL MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

6. Rolls ball Parental report

interactively with will suce
caregiver/ examiner

7. Hugs or cuddles toys Parental report

will suce

8. Demonstrates Parental report

respect for elders will suce
using terms like
po and opo

9. Shares toys with Parental report

others will suce

10. Imitates adult Parental report

activities (e.g., will suce
cooking, washing)

11. Identifies feelings in Credit if the child

others can tell when
the caregiver is
feeling happy,
sad, worried, etc.
Parental report
will suce.

12. Appropriately uses Parental report

cultural gestures of will suce.
greeting without
much prompting
(e.g., mano, bless,
kiss, etc.)

13. Comforts Parental report

playmates/siblings will suce.
in distress

14. Persists when faced Credit if the child

with a problem tries to solve the
or obstacle to his problem instead
wants of crying when
something stands
in the way of
what he wants
(e.g., fastening
a box of his
treasures with a
string if the lid no
longer closes).
Parental report
will suce.

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 SOCIAL-EMOTIONAL MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

15. Helps with family Parental report

chores (e.g., wiping will suce.
tables, watering
plants, etc.)

16. Curious about Credit if the child

environment but asks questions
knows when to stop about things
asking questions of around him but
adults knows when he is
being makulit
about the topic
Parental report
will suce.

17. Waits for his/her Parental report

turn will suce.

18. Asks permission to Parental report

play with toy being will suce.
used by another

19. Defends possessions Credit if the child

with determination tries to hold on to
what is his when
someone tries to
grab this from
him.
Parental report
will suce.

20. Plays organized Parental report

group games fairly will suce.
(e.g., does not cheat
in order to win)

21. Can talk about Parental report

complex feelings will suce.
(e.g., anger,
sadness, worry) he
experiences

22. Honors a simple Parental report
bargain with will suce.
caregiver (e.g., plays
outside only after
cleaning / fixing his
room)

23. Watches responsibly Parental report

over younger will suce.
siblings/family
members

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 SOCIAL-EMOTIONAL MATERIALS/ P O R COMMENTS P O R COMMENTS
DOMAIN PROCEDURE

24. Cooperates with Parental report

adults and peers in will suce.
group situations to
minimize quarrels
and conflicts

TOTAL SCORE

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 Examiners Notes
Write down your notes, descriptions and observations on the columns provided.

Name of examiner: Name of examiner:

Date administered: Date administered:
Place of test: Place of test:

Childs background (ex. behavior/ health/ etc.) Childs background (ex. behavior/ health/ etc.)

Family environment (ex. health of family Family environment (ex. health of family
members/family problems/economic conditions/ members/family problems/economic conditions/
etc.) etc.)

Parents stimulating activities for the child (What Parents stimulating activities for the child (What
are the activities/things that the parents do to are the activities/things that the parents do to
help stimulate the childs development) help stimulate the childs development)

Home environment (ex. facilities/type of house/ Home environment (ex. facilities/type of house/
household items/interaction/etc. household items/interaction/etc.

Others: Others:

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Transfer the raw score for each domain in the table below. Using the Scaled Scores Equivalent of Raw Scores
Table, convert the raw scores to Scaled Scores appropriate to the age of the child. To arrive at the Sum of Scaled
Scores, add the Scaled Scores across all domains. To derive the Standard Score, refer to the Standard Score
Equivalent of Sums of Scaled Scores Table. Write the Childs age on each evaluation.

AGE
1st Evaluation Date 2nd Evaluation Date
DOMAIN
Childs Age Childs Age
Raw Score Scaled Score Raw Score Scaled Score
Gross Motor
Fine Motor
Self-Help
Receptive Language
Expressive Language
Cognitive
Social-Emotional
Sum of Scaled Scores
Standard Score
Date Tested

Scaled Score Interpretation Standard Score Interpretation

1 - 3 Development in the domain 69 and below Overall development must be
must be monitored after 3 monitored after 3 months
months
70-79 Overall development must be
4 - 6 Development in the domain must monitored after 6 months
be monitored after 6 months
80-119 Average overall development
7 - 13 Average overall development in
the domain 120-129 Suggest slightly advanced
development
14 - 16 Suggest slightly advanced
development in the domain 130 and above Highly advanced overall
development
17 - 19 Suggest highly advanced
development in the domain

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 Scaled Scores

Mark an X on the dot corresponding to the Scaled Score for each domain and connects the Xs. Write the childs
age on each evaluation.

28
 Standard Scores

Mark an X on the corresponding Standard Score for each administration and connect the Xs. Write the date for
each test administration.

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Ensure the best possible start in your childs life. Monitor your childs development.

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