Name of Barangay: ___________________________ Municipality:___________________________

Division:____________________________________ Region:_______________________________
TOOL FOR MAPPING OF 4-17 YR. OLD CHILDREN
Name Gender Relationship Is resident If YES, indicate Age Date of With Birth
Last First Middle to the permanent Number Birth Certificate
Household (Y/N) Home of years
Address in said
address

1 ASK: "Is the child a permanent resident?" (YES/NO) If YES, follow up "do the residents plan on moving out?"
2 TYPES OF DISABILITIES: (see DepED Order No. 2, s 2014 for detailed descriptions)
1- Visual Impairment 6- Serious emotional disturbance
2- Hearing Impairment 7- Autism
3- Intellectual Disability 8- Orthopedic impairment
4- Learning Disability 9- Special health problems
5- Speech/language impairment 10- Multiple disabilities
 If 3-4 years old Highest Is If YES, If NO, state
If Provide If YES, Educational currently What Name If thru reason for
Ethnicity Religion disability d with specify Attainment studying? level of ADM not
, specific ECCD ECCD Completed (Y/N) School specif studying
type 1 services facility 2/ y what
type
of
ADM
 NAME DEMOGRAPHIC INFORMATION RESIDENCE DISABILITY
Last First Middle Gender Age Date of With Birth Present Is Number Has a
Birth Certificate Address resident of years disability?
permane in said (YES/N0)
nt? address?
(Y/N)
DISABIL ECCD (4YO EDUCATIONAL STATUS
ITY CHILDREN)
If yes Provided If YES, Education Currently If YES, state If NO, state If Planning to If YES, If NO, state
specify with specify al Studying? name of reason for studying study next specify the reason for
type of ECCD ECCD Attainme (YES/NO) school not studying through school name of not planning
diasabili services? facility? nt ADM, year? perspective to study
ty (YES/NO) specify of (YES/NO) school next school
ADM year